Common use of PSYCHOLOGICAL SERVICES Clause in Contracts

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client/patient in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Each of our therapists also has corresponding responsibilities to you. These rights and responsibilities are described herein. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, grief, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has scientifically been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen or what results will be gained. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. ! In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectus. If you have questions about my proceduresany of our procedures or recommendations, we should discuss them whenever they arise. APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, several times per month, at a time that we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with at least 24 hours’ notice. If you miss a session without cancelling or cancel with less than 24 hours’ notice, you are agreeing to pay the full fee for that time (unless we both agree that you were unable to attend due to circumstances that were beyond of your doubts persistcontrol). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, I you will be happy responsible for the standard fee as described above. If it is possible, we will try to help find another time to reschedule the appointment. In addition, you set up a meeting with another mental health professional are responsible for a second opinioncoming to your sessions on time. Please note that If you are late, your appointment will still need to end at the psychological services I provide are not predetermined scheduled time. PROFESSIONAL FEES The standard fee for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 175.00 and $250 for each subsequent psychotherapy session (either in-person is $125.00. You are responsible for paying at the time of your session unless prior arrangements and billing agreements have been made. Payments may be made by credit, checks or over cash. Any checks returned are subject to an additional $25.00 fee to cover the telephone) lasting 45 minutesbank fees the will incur. I If you refuse to pay your debt, we reserve the right to use an attorney or collection agency in the future to secure payment. In addition, to weekly appointments, it is our practice to charge this same $250 per 45-minutes rate amount on a prorated basis (we will break down the hourly costs) for other professional services that you may needrequire or request such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone or teleconferencing conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations, or the time spent performing required to perform any other service which you may request of meus. If you become anticipate becoming involved in legal proceedings a court case, we recommend that require my we discuss this fully before you waive your right to confidentially. If your case requires our participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for party compels us to testify or participate in any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:proceedings.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client/patient in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Each of our therapists also has corresponding responsibilities to you. These rights and responsibilities are described herein. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, grief, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has scientifically been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen or what results will be gained. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. ! In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectus. If you have questions about my proceduresany of our procedures or recommendations, we should discuss them whenever they arise. APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, several times per month, at a time that we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with at least 24 hours’ notice. If you miss a session without cancelling or cancel with less than 24 hours’ notice, you are agreeing to pay the full fee for that time (unless we both agree that you were unable to attend due to circumstances that were beyond of your doubts persistcontrol). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, I you will be happy responsible for the standard fee as described above. If it is possible, we will try to help find another time to reschedule the appointment. In addition, you set up a meeting with another mental health professional are responsible for a second opinioncoming to your sessions on time. Please note that If you are late, your appointment will still need to end at the psychological services I provide are not predetermined scheduled time. PROFESSIONAL FEES The standard fee for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 150.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements and billing agreements have been made. Payments may be made by credit, checks or over cash. Any checks returned are subject to an additional $25.00 fee to cover the telephone) lasting 45 minutesbank fees the will incur. I If you refuse to pay your debt, we reserve the right to use an attorney or collection agency in the future to secure payment. In addition, to weekly appointments, it is our practice to charge this same $250 per 45-minutes rate amount on a prorated basis (we will break down the hourly costs) for other professional services that you may needrequire or request such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone or teleconferencing conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations, or the time spent performing required to perform any other service which you may request of meus. If you become anticipate becoming involved in legal proceedings a court case, we recommend that require my we discuss this fully before you waive your right to confidentially. If your case requires our participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for party compels us to testify or participate in any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:proceedings.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychological counseling varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. InsteadCounseling will frequently involve discussing your personal concerns, it calls for a very active effort on your partthoughts, and feelings. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homebetween sessions. We believe that homework assignments are a necessary part of the recovery process, thus we only work with clients who are willing to engage in homework assignments. Psychotherapy can have benefits risks and risksbenefits. Because therapy often involves discussing unpleasant aspects of your life, Initially you may experience uncomfortable feelings like levels of sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, or other negative feelings. When treating insomnia specificallyWhile you consider these risks, you should also know that the benefits of therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also have been shown to have benefits for people who go through itby scientists in hundreds of well-designed research studies. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleepimprovement in relationships, acquisition of skills to cope with stress, and less fatigueimprovement in overall well-being. But there are no guarantees as to of what you will experience. Our first session few hours together will involve an evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtogether. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we should discuss them whenever they arise. If We are happy to provide outside referrals if your doubts concerns persist. MEETINGS AND CANCELLATION POLICIES We offer both 50-minute “traditional” appointments as well as an “Intensive Therapy” model (e.g., I 2-6 hours at a time; multiple days per week). The exact timing of sessions will be happy determined in consultation with you, based on your needs. A phone consultation is recommended prior to help you set up a meeting with another mental health professional for a second opinionarranging treatment. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest The 15-minute increment (e.g.consultation will be done free of charge. During the consultation, 22 minutes of service we can both decide whether I am the best match to provide the services you need. Once an appointment is scheduled, you will be charged for 15 minutes whereas 23 minutes it unless you provide 48 hours advance notice of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings cancellation (unless we both agree that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying unable to attend due to circumstances beyond your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of servicecontrol), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Your appointment will involve an evaluation of your needs. By the end of the evaluation, your clinician will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, the Counseling Center may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your clinician include services that the Counseling Center cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information received from the clinician who met with you along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your clinician, please discuss them whenever they arise. If your doubts persist, your clinician will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your clinician, and the personalities of the psychologist clinician and patient, and the particular problems you hope to addressclient. There are many different methods I clinicians may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very an active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about that are discussed both during our your sessions and at homeon your own. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience a variety of uncomfortable feelings like sadnessfeelings. The changes you make in therapy may also affect your relationships in unexpected ways. Also, guiltcertain psychological conditions, angersuch as suicidal states, frustration, loneliness, and helplessnessmay result in death regardless of the interventions of the clinician. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy Psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, and improved sleepmood, functioning, and less fatigueoverall quality of life. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will The clinician with whom you meet may be able to offer you some first impressions of what our work will include and supervised by a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectsenior clinician. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that is the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationcase, you will be expected informed about this by your clinician. For professional development, your clinician may request your permission to pay for any professional time I spend audio or video-record your session(s). No recording will be done without your prior knowledge and consent. Only the supervisors or consultants directly involved in consulting on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecase will have access to those recordings. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these The recordings will be discussed and agreed erased upon ahead completion of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed supervision or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:consultation.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patient, and the particular problems you hope to address. There are many different methods I your therapist may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy psychotherapy to be most successful, you will have to work on things we you and your therapist talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some discuss his or her first impressions of what our work will include and provide a treatment plan to followfor treatment, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I your therapist will notify you if I believe he or she feels this is a good match for both parties. If your therapist concludes that I am he or she may not be the right therapist for you and if soyou, I will give you referrals to other practitioners who I believe are better suited to help youmeet your needs will be provided. It is the Good Life Center for Mental Health, LLC’s policy to obtain relevant past treatment and concurrent information provided by other professionals and at mental health facilities, if applicable. Thus, you may be asked to sign authorizations that allow for these records to be released to us. While we respect your right to refuse access to records, Good Life Center for Mental Health LLC reserves the right not to enter into a therapeutic agreement if access to prior mental health records is denied. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresyour therapist’s modality of work, we should please discuss them whenever they ariseopenly with him or her. If your doubts persist, I your therapist will be happy to help assist you set up a meeting in securing consultation with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. There are many different methods I may use to deal with those problems. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. My work may include a variety of activities, and for optimum outcomes to occur, your active participation is essential. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, self-doubt, anxiety, depression, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause There are no guarantees as to what you to experience increased sleepiness and fatigue, especially in the early phases of treatmentwill experience. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. While I am a trained, improved sleeplicensed and experienced psychologist, and less fatigue. But there are no guarantees as I will attempt to what help you achieve your goals, but I cannot guarantee change nor can I promise that all problems will experiencebe resolved. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and and, if so, I will give you referrals to other practitioners who whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another provide names of other mental health professional for professionals with whom you can seek a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciesSESSIONS If we agree to begin psychotherapy, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than usually schedule one 45 minutes in increments of 15 minutes, rounded to the nearest 1555-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another partysession per week or, at the same $250 per 45-minutes ratea time and frequency that we agree on. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I Depending on progress, session lengths may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:vary.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities a set of the psychologist and patientpsychological interventions designed to help people resolve emotional, behavioral, and interpersonal problems and improve the particular quality of their lives. There are many different interventions I may use to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it Cognitive-behavioral psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, it will be important for you will have to work on the things we talk about about, both during our sessions and at home. Psychotherapy can have both benefits and risks. Because therapy Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience transient uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads may lead to better relationships, solutions to specific problems, better relationships, and significant reductions in feelings of distress. During our first few sessions, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve I typically conduct an evaluation of your treatment needs. By the end of the evaluationthis evaluation process, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should are encouraged to evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss can address them whenever as they arise. If your doubts persistShould you request a second opinion, I will be happy to help refer you set up a meeting with to another mental health professional professional. PROFESSIONAL FEES In addition to fees for weekly appointments, I may charge a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either inpre-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate determined amount for other professional services you may need, though I will prorate break down the cost if I work for periods of less than 45 minutes in increments of 15 one hour. Other services for which you may be billed include report writing, conversing with you by telephone if the conversation lasts longer than a few minutes, rounded to the nearest 15-minute increment (e.g.consulting with other professionals with your permission, 22 minutes preparation of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations treatment summaries or email responses lasting longer than 15 minutessimilar records, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. APPOINTMENTS AND CANCELLATION POLICY I typically conduct an evaluation during the first session, at which usually lasts 90-120 minutes. During this time, we can both decide if I am the same $250 per best person to provide the services you need to meet your treatment goals. If psychotherapy has begun, we will usually schedule one 45-minutes rate. I do not charge for 50 minute session per week at a time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timewe agree on, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which though some sessions may be higher than the fee you were previously payinglonger or more frequent. In addition, if it has been more than one year since our last appointmentUnless an appointment is cancelled 24 hours in advance, you will be charged in full for the missed appointment. I require one full business day’s notice for cancelled or rescheduled appointments. This means that appointments scheduled for another initial evaluation Mondays need to be cancelled or rescheduled by the end of business on the Friday before the scheduled appointment, or you will be charged for the missed appointment. This policy applies to changes in work schedules or childcare arrangements. Documented emergencies (90 minutese.g., going to the Emergency Room) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You or regional weather emergencies are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide the only exceptions to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do sothis policy. However, frequent or repeated cancellations for illness will be aware that the services provided billed at my discretion. Additionally, you will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:late arrivals. It is important to note that insurance carriers do not reimburse for missed appointments.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per APPOINTMENTS Appointments will ordinarily be 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 50 minutes in increments of 15 minutesduration, rounded once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved in legal proceedings that require my participation, you will be expected need to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timecancel or reschedule a session, I may institute fee increases and these will be discussed and agreed upon ahead of time ask that you provide me with a new Treatment Contract24 hours notice. If it has been more than one year since our last is possible, I will try to find another time to reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL RECORDS I am required to keep appropriate records of the full paymentpsychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have no role in deciding what the right to a copy of your insurance coversfile. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You are responsible for checking also have the right to request that a copy of your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely file be responsible for the full session fee in these instances. If made available to any other health care provider at your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. DISCUSSION OF TREATMENT PLAN Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not You also have the right therapist to ask about other treatments for you your condition and if so, I will give you referrals to other practitioners who I believe are better suited to help youtheir risks and benefits. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Xxxxx Xxxxx, LCSW as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per APPOINTMENTS Appointments will ordinarily be 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 60 minutes in increments of 15 minutesduration, rounded to the nearest 15-minute increment (e.g.once per week at a time we agree on, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which although some sessions may be higher than the fee you were previously payingmore or less frequent as needed. In addition, if it has been more than one year since our last appointment, you will be The time scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If appointment is assigned to you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:alone.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relaHonship between people that works in general statementspart because of clearly defined rights and responsibiliHes held by each person. It varies depending on the personalities of the psychologist As a client in counseling, you have certain rights and patient, and the particular problems responsibiliHes that are important for you hope to addressunderstand. There are many different methods I also legal limitaHons to those rights that you should be aware of. I, as your counselor, have corresponding responsibiliHes to you. These rights and responsibiliHes are described in the following secHons. Counseling has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustraHon, loneliness and helplessness, because the process of counseling xXxx requires discussing the unpleasant aspects of your life. However, counseling has been shown to deal with those have benefits for individuals who undertake it. Counseling xXxx leads to a significant reducHon in feelings of distress, increased saHsfacHon in interpersonal relaHonships, greater personal awareness and insight, increased skills for managing stress and resoluHons to specific problems. Psychotherapy is not like a medical doctor visitBut, there are no guarantees about what will happen. Instead, it calls for Counseling requires a very active effort acHve effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2 to 4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation a comprehensive evaluaHon of your needs. By the end of the evaluationevaluaHon, I will be able to offer offer you some first iniHal impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an iniHal treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with informaHon and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions quesHons about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, rage, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and finding resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homediscuss outside of therapy sessions. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of If you practice using the skills that I will teach you, you should see beneficial changes in your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our The first session few sessions will involve an a comprehensive evaluation of your needsclinical needs and treatment goals. By the end of the evaluationevaluation period, I will be able to offer you some first initial impressions of what our work might include. We will include discuss your treatment goals and a develop an initial, working treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help refer you set up a meeting with to another mental health professional for professional. It is important to feel like you and your therapist are a second opiniongood fit. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either inAPPOINTMENTS Appointments will ordinarily be 50-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 55 minutes in increments of 15 minutesduration, rounded typically once per week at a time we agree on, although sessions may be more or less frequent as needed. Trauma processing with EMDR or Brainspotting may at times require a 75 minute session. Couples therapy sessions are typically an hour and a half. The time scheduled for your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved need to cancel or reschedule a session, I ask that you provide me with at least 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you will still be responsible for full payment for the appointment. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will not be reimbursed. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL FEES & PAYMENTS As can be expected, my fees vary depending on the service provided and the amount of time spent providing counseling or other services. Payment may made by check, cash or credit card. There is a $5 service fee for credit card processing. We have discussed the current fees and you agree to pay for services provided. You are responsible for paying in legal proceedings that require full at the time of your session unless prior arrangements have been made with me or my participationassistant. If any checks are returned for insufficient funds, you will be expected to fully reimburse me for any fees that I may incur. If you refuse to pay your debt, WBP reserves the right to use an attorney or collection agency to secure payment. If you wish to make alternative arrangements around payments, please discuss this possibility with me. In addition to your appointments, it is my practice to charge an hourly amount on a prorated basis for other professional services that you may require such as report writing, phone conversations that last longer than 15 minutes (I will advise you before charging a fee,) attendance at meetings or consultations which you have requested (if I am available,) or the time required to perform any other service which you may request of me that I agree to perform. PAYMENT & INSURANCE ISSUES In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I am on a number of insurance panels. If you want this office to file a claim with your insurance carrier, contact your insurance company so you can obtain any necessary authorization for your treatment. Managed Health Care plans such as HMOs and PPOs may require advance authorization, without which they may refuse to provide reimbursement for mental health services. If you plan to use your in-network insurance, please contact your insurance company to verify your benefits. You will want to determine the amount of your deductible, copayments and coinsurance for outpatient mental health services in an office setting (ex: CPT psychotherapy code 90837.) Please also contact my office assistant or me prior to our first session to provide us with your insurance information. Please provide us with the information on the financial intake form on xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx. You will be responsible to pay any co-payments, coinsurance and deductibles at the time of service. If I am not an in-network provider for your insurance company, you will need to pay me in full at the time of service. You will need to check to see if you have out of network benefits in your plan, if you intend to file a claim and I am not in your insurance network. Please note that most but not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider in your network, I can help refer you to a colleague. If you would like to file a claim with your insurance carrier for any out of network benefits, please ask and I will provide you with a billing document of the services provided, dates of sessions, a diagnosis, and fees paid. I can provide this weekly, monthly or as needed. If a family member is going to assist you with treatment costs, they may choose to pay me directly. If so, I will need you to sign a consent for release of information form to speak with them about finances and continuation of therapy. I will need payment at the time service is provided. PROFESSIONAL RECORDS I am professionally required to keep appropriate records of the psychological services that I provide. The confidentiality of your records and our communications are protected by The Health Insurance Portability and Accountability Act of 1996. Your records are maintained in a secure location. I keep records noting dates that you were here, your reasons for seeking therapy, the goals we set for treatment, your diagnosis, your progress, topics we discussed, conversations we had including things you said, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Your insurance company may ask me to provide additional clinical information such as treatment plans or summaries to justify your continued care. You will need to sign a release of information if you wish for me or my office assistant to communicate with your insurer. Any provided information will become part of the insurance company files. Insurers may share the information with a national medical information database. You have the right to a copy of your medical file, except in unusual circumstances that involve potential emotional damage or danger to yourself. You may request a copy by completing and submitting a release form. Because these are professional records, it is possible that they may be misinterpreted or upsetting to untrained readers. For this reason, if you would like a copy, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents with you. You also have the right to request that a copy of your file be made available to other health care providers when you request them and sign a Consent to release information form for that provider. CONFIDENTIALITY Our relationship and conversations are confidential with certain exceptions listed below. Please remember that you may reopen the conversation about confidentiality at any time during our work together. Also, if I spend on see you in public, I am happy to see you but to protect your legal matterconfidentiality I will not speak to you unless you speak to me first. I will not tell people that you are with how we know each other, even if the request comes from but you may. LIMITS OF CONFIDENTIALITY At times, you may want to authorize me to provide diagnostic and treatment updates verbally or in writing to third parties such as your physicians, insurance company, attorney, or family members. You need to provide written or verbal consent for me to provide them any information. If you provide written or verbal consent for me to release your confidential information to another party, at then I may release the same $250 per 45-minutes rateinformation that you agreed to release until you rescind such authorization in writing. Any disclosures of information prior to receiving your request to rescind your release are not affected by this action. I do may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required: · Emergency: If you are involved in in a life-threatening emergency and I cannot charge for time spent writing reports and progress notes as per the standard routine of my care of ask your permission, I will share information if I believe you would have wanted me to share, or if I believe it will be helpful to you. · Child Abuse Reporting: If I also do not charge for any time have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately to the Department of Child and Family Services. I am a mandated reporter of suspected abuse or neglect. · Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by law to immediately make a report and provide relevant information to the Department of Child and Family Services. I may spend collaborating use contractors to assist with your other providersadministrative functions. From time to timeContractors must sign a confidentiality and non-disclosure agreement. At times, I may institute fee increases and these will be discussed and agreed upon ahead confidentially discuss details of time your care with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled licensed clinical consultant for another initial evaluation (90 minutes) clinical direction and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesassistance. If you decide to submit claims communicate with me via text or email, by doing so you understand that these forms of communication are not secure. I suggest you restrict this type of communication to verifying appointment times. CONTACT Feel free to call, text or email me to reschedule your insurance company for reimbursement for any out-of-network benefits you might haveappointment. I am not usually immediately available by telephone. I do not answer my phone when I am with clients, after hours, on vacation, or when otherwise unavailable. At these times, you may do so. Howevertext me, email me, or leave a message on my confidential voice mail and your call will be aware that the services provided will still be charged to youreturned as soon as possible, not your insurance company, and you are responsible but it may take a day or two for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, prenon-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseurgent matters. I will provide try to reach you a superbill after each session with the following information that as soon as I can. If you are difficult to reach, please leave times you will need be available. If you want me to submit use discretion when calling you or leaving a message for you, please let me know in advance. I will try to your insurance company for reimbursement for any out-of-network benefits contact you might have:if you miss an appointment.

PSYCHOLOGICAL SERVICES. Psychotherapy Psychological treatment is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use that can be used to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, in that it calls for a very active effort on your part. In order for the therapy to be most successful, you will may have to work on things we talk about both during our sessions and at home. Psychotherapy Psychological treatment can have both benefits and risks. Because therapy Treatment often leads to significant reductions in feelings of distress, as well as improvements in specific problems and relationships. But there are no guarantees of what you will experience, and it is possible that you may not become happier. Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially helplessness in the early phases course of treatment. On the In some cases there may be increased conflict or other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better undesirable changes in relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session initial discussions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to followinclude, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about judgment of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting secure an appropriate consultation with another mental health professional if you desire one. For reasons of professional ethics, I generally avoid multiple relationships with clients, such as doing assessments (beyond those needed for treatment) or forensic services with therapy clients. MEETINGS I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the right person to provide the services that you need. If treatment is begun, I will usually schedule one 45-minute session per week at a second opinionmutually agreed time, although sometimes sessions may be longer or scheduled at other intervals. Please As much as possible, I expect all matters, including financial, to be discussed during sessions. Once an appointment is scheduled, you will be expected to pay for it unless you call or write me (not text) at least 24 hours in advance to cancel, unless we both agree that you were unable to attend and unable to provide 24 hours notice due to circumstances beyond your control. In the latter case there will be a $20 late cancellation fee. Otherwise, if you miss or cancel an appointment with less than 24 hours advance notice, you will need to pay for the appointment in full (not just your insurance co-payment). It is important to note that the psychological services I insurance companies almost never provide are not reimbursement for emergency situationscancelled sessions. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My usual fee is $395 150 for an initial evaluation lasting 90 minutesa 45-minute individual psychotherapy, and $250 for each subsequent psychotherapy session (either in-person hypnosis or over the telephone) lasting 45 minutescouple/family session. In addition to regular appointments, I charge this same $250 per 45-minutes rate 150/hr on a prorated basis for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutessuch as psychological testing, rounded to the nearest 15-minute increment (e.g.preparing letters or other documents, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 10 minutes, meetings or consultations which you have authorized, review or preparation of records or treatment summaries, and the time spent performing any other service you may request of me. A discounted fee may apply if an insurance plan or Employee Assistance Program in which I participate covers the services. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. I will not voluntarily appear in court on your behalf unless we have discussed the matter thoroughly, and we both agree that the court appearance will not interfere with the treatment relationship. Because of the difficulties of legal involvement, I charge $300 per hour for participation in any legal proceeding, and I generally require payment of all or part of such fees in advance. I can provide you with a detailed schedule of my professional fees in legal matters. BILLING AND PAYMENTS You will be expected to pay for each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not You agree to pay the full charge for time spent writing reports missed appointments, not just the copayment or coinsurance, unless you cancel 24 hours in advance or are unable to cancel 24 hours in advance. If your account has not been paid for more than 60 days and progress notes as per the standard routine of my care of you. I also do arrangements for payment have not charge for any time I may spend collaborating with your other providers. From time to timebeen agreed upon, I have the option of using legal means to secure the payment. This may institute fee increases and these involve using a collection agency or small claims court which will require me to disclose otherwise confidential information. If such legal action is necessary, its costs will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than included in the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterclaim. INSURANCE REIMBURSEMENT You are responsible In order for paying us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your full session fee. I am not in-network with any insurance companiestreatment. If you decide have a health insurance policy, it is likely to submit claims provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coveragepayment of my fees, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), unless this is prohibited by a contract between me and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse youor other healthcare organization that covers your behavioral-health benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseshould call your plan and inquire. Of course, I will provide you a superbill after each session with whatever information I can, based on my experience, and will help you in understanding the following information that you will need to submit to receive from your insurance company. I may be willing to call the company for reimbursement for any out-of-network benefits on your behalf. However, because of the complexity of insurance claim processing, you might have:cannot assume that my understanding of your coverage will always be correct.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note MEETINGS I will normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the psychological best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy will usually schedule one 50-minute session (either in-person one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or over the telephone) lasting 45 minutesmore frequent. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment hour is scheduled, you will be expected to pay for any professional time I spend on it unless you provide 48 business hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol]. I It is important to note that insurance companies do not charge provide reimbursement for time spent writing reports and progress notes as per the standard routine of my care of youcancelled sessions. I also do not charge for any time I may spend collaborating with Please note, if you cancel your other providers. From time to timeappointment within 48 business hours, I may institute fee increases and these you will be discussed and agreed upon ahead of time with charged a new Treatment Contract$50 late cancellation fee, unless I am able to rebook the appointment. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than cancel the fee you were previously paying. In addition, if it has been more than one year since our last day of your appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:$125 charge.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist psychotherapist and patient, patient and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should can discuss them whenever they arise. SESSIONS Each individual session lasts either 45 or 60 minutes and family sessions are 60-80 minutes. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional are late for a second opinionsession, that time is lost from your session. Please note If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that the psychological services I provide are cannot for emergency situations. For emergenciesbe offered to anyone else, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be charged meeting. If you cannot make it to the appointment for 30 minutes). Other professional services include telephone conversations weather reasons, please call or email responses lasting longer than 15 minutesme by 8:00 a.m. (000-000-0000 or xxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 11/2/2017 PROFESSIONAL FEES Please confirm current fees with therapist: for 45-minute sessions for 60-minute sessions ______ for 75-minute sessions Additional time is billed at $50 per quarter hour. These fees are also billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time spent performing any other service of the session by cash, check or credit card. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may request pay me out of mepocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal matterand expenses, including preparation costs, transportation costs, and attorney’s fees, even if the request comes from I am called to testify by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, at I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then day you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordinglymake it, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesthe exception of weekends and holidays. If you decide are unable to submit claims reach me and feel that you can’t wait for me to return your insurance company for reimbursement for any out-of-network benefits you might havecall, you may do so. However, be aware that contact your family physician or the services provided will still be charged to you, not your insurance company, nearest emergency room and you are responsible ask for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancespsychologist or psychiatrist on call. If your insurance company doesn’t reimburse youI will be unavailable for an extended time, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will need view it as your agreement to submit take the risk that such communication may be intercepted, and will honor your desire to your insurance company communicate on such matters via email or text. Please do not use email or text for reimbursement for any out-of-emergencies. Due to computer or network benefits you might have:problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

PSYCHOLOGICAL SERVICES. Psychotherapy The way therapy is not easily described in general statements. It varies depending conducted and the outcomes that occur depend on the personalities of the psychologist particular issues you bring forward and patient, how you and the particular problems you hope your therapist choose to addressapproach them. There are many different methods I may use to deal with those problems. Psychotherapy Therapy is not like going to a medical doctor visitdoctor. Instead, it calls for It is a very more collaborative process that requires trust and open communication. It requires active effort participation on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our the sessions and at homehome between sessions. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentfeelings. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads therapy can lead to better management of your health and medical conditions, improved relationships, solutions to specific problems, significant and reductions in feelings of distress, improved sleep, and less fatiguestress. But there There are no guarantees as to of what you will experience. Our first session will involve an evaluation of If you have any questions or concerns about your needswork with your therapist, it is important to share those with your therapist. By You have the end of the evaluation, I will be able right to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for ask questions about anything that happens in therapy. You should evaluate this information along with are free to leave therapy at any time, but it is usually best to talk about your own opinions about whether concerns first. If you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe decide that I am your therapist is not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help can provide you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractreferral to another therapist. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than CANCELLATION POLICY We reserve the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide right to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for charge the full session fee for any scheduled appointment that is missed or is cancelled with less than 24 hours notice. However, if we are able to reschedule the appointment with your therapist for a mutually agreeable time during the same week as the scheduled appointment, we will only bill for the new appointment. Of course, we cannot guarantee that your therapist will have alternate appointment times available. PHONE CALLS We always try to return phone messages promptly. Even on days that we are not in these instancesthe office, we check my voicemail several times per day. In your message, please let us know if you want us to call you back and, if so, the best time and phone number for us to reach you. If you do not receive a return call from us within a reasonable amount of time please leave a second message (occasionally, voicemail systems fail) or send an email to Xxxx0XXXX@Xxxxx.xxx as backup. There may be occasion when our office needs to contact you by telephone to schedule a new appointment or change the day or time of your insurance company doesn’t reimburse younext appointment. If you do not answer, we may want to leave a message that identifies the call as coming from Bay Area Health Psychology. If you do not agree and approve of our leaving a message on our home phone or cell phone, indicate this by putting your initials on the appropriate line below and bring this to my attention. In this case, I am will indicate on your clinical record that we will not responsible for refunding you any payment you expected to be reimbursed leave messages on your home phone or otherwisecell phone. I will give my permission for any provider or staff member of Bay Area Health Psychology to leave a voice message on my home phone and/or cell phone regarding appointment scheduling. Do NOT leave any voice message on my home phone or cell phone for any reason, including appointment scheduling. EMAIL AND TEXT MESSAGING Your therapist might use email and text messaging ("texting") as alternate means of communication. This enables you to send email and text messages if you need to convey information to your therapist. However, please note that email and text messaging are not secure modes of communication. Emails and text messaging are best used for scheduling appointments or dealing with payments. We recommend that you do not send clinical information of a personal or confidential nature via email or text, or ask us to respond to you with personal or confidential information. However, there may be occasions when you want or need to send clinical information to your therapist via email or text message, and there may be occasions when you want your therapist to provide you a superbill after each session with the following clinical information via email or text message. There may also be occasions when your therapist believes it is necessary to send you clinical information via email or text messaging. Email and text message may be preferred and necessary when (a) it is important that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:information be received quickly,

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24-hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the amount of your payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 150.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by before the session Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientDuring our first few sessions, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you we will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause discuss what brought you to experience increased sleepiness and fatigue, especially in the early phases of treatmenttherapy. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you These sessions will experience. Our first session will involve an evaluation of your needstypically include informal (unstructured) assessment. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour doctor. If you have questions about my our procedures, we should discuss them whenever they arise. If A few things to remember: ∙ Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your doubts persistpart. You will likely have "homework" to complete between sessions. ∙ Sometimes undesirable behaviors increase in intensity before they lessen when you start addressing them. This is normal and usually temporary. ∙ Psychotherapy can have benefits and risks. These may vary depending on your reason for coming to therapy. While there are no guarantees of what you will experience, I will most people benefit from therapy. Benefits may include improved sleep, better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, because therapy may involve discussing challenging aspects of your life, you could at times experience difficult emotions or discomfort. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:  You should be happy to help you set up a meeting with another aware that the office includes other mental health professionals and administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality.  We have a contract with Medical Billing Associates. As required by HIPAA, we have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with a blank copy of this contract.  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.  If a patient threatens to harm himself/herself, the doctor may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where your doctor is permitted or required to disclose information without either your consent or Authorization:  If you are involved in a court proceeding and a request is made for information concerning our professional for services, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a second opinioncourt order. Please note that the psychological services I provide If you are not for emergency situationsinvolved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. For emergencies, call 911 or go If you do request your information to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes be shared in increments of 15 minutes, rounded to the nearest 15-minute increment a legal matter (e.g., 22 minutes Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of service $185.00/hour will be charged applied for 15 minutes whereas 23 minutes preparation of service will be charged a clinical summary, as it is our policy not to share clinical notes with anyone besides other healthcare professionals. This is for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutesyour protection, as they are written in clinical, not legal language, and the time spent performing any information contained in them could be misinterpreted.  If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.  If a patient files a complaint or lawsuit against either doctor or the practice, we may disclose relevant information regarding that patient in order to defend ourselves.  If a patient files a worker’s compensation claim, and we are providing treatment related to the claim, we must, upon appropriate request, furnish copies of all medical reports and bills. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in this practice.  If your doctor has reason to believe that a child has been abused, the law requires that she file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, we may be required to provide additional information.  If your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other service you than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may request be required to provide additional information.  If your doctor determines that a patient presents a serious danger of meviolence to another, she may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, your doctor will make every effort to fully discuss it with you become involved before taking any action and she will limit her disclosure to what is necessary. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in legal proceedings that require my participationyour records; and the right to a paper copy of this Agreement, you the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not charge Payment schedules for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these professional services will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You to when they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesrequested. If your insurance company doesn’t reimburse youaccount has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I am not responsible for refunding you any payment you expected we have the option of using legal means to be reimbursed secure the payment. This may involve hiring a collection agency or otherwisegoing through small claims court which will require us to disclose otherwise confidential information. I will provide you In most collection situations, the only information we release regarding a superbill after each session with patient’s treatment is his/her name, the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:nature of services provided, and the amount due. INTERNET CONTACT

PSYCHOLOGICAL SERVICES. Assessment and Psychotherapy Psychological assessment usually involves interviewing you to find out the details of the problem which is being assessed and administration of a number of psychological tests designed to measure different kinds of psychological factors like IQ, personality, academic skills, memory, problem solving, and others. The tests are scored and interpreted according to well researched standards and a report is written describing the findings and, often, the sorts of things you can do to help resolve the problem. Your therapist will meet with you to discuss the test results and recommendations, and in most cases you may also have a copy of the written report. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your therapist may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we you and your therapist talk about both during our therapy sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experienceexperience or the results or outcome of your therapy. Our Your first session few sessions will likely involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first impressions of what our kinds of things you will work will include on in therapy and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour therapist. If you have questions about my procedures, we you and your therapist should discuss them whenever they arise. If your doubts persist, I your therapist will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. FEES My fee initial intake and each subsequent session is $395 125, unless you have received a fee reduction, in which case you will owe the amount we agreed upon, written at the bottom of this form. You are responsible for paying at the beginning of your session unless prior arrangements have been made. Payment must be made by check, cash, or credit. Any checks returned to my office are subject to an initial evaluation lasting 90 minutesadditional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, and $250 for each subsequent psychotherapy session (either in-person I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. As a licensed psychologist I provide psychotherapeutic services, including psychotherapy and assessment services, to adolescents and adults through individual and group psychotherapy. I utilize a variety of approaches including cognitive-behavioral therapy, mindfulness, acceptance and commitment therapy, cognitive processing therapy. Every individual and situation is unique and requires an individualized approach to treatment. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and benefits, but also has potential risks. Because It may be painful to approach thoughts and feelings that you have tried to avoid for a long time. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, or frustration. Making changes in your life, lonelinessyour beliefs, or behaviors can be uncomfortable and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentscary at times. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant increased self-understanding, reductions in feelings of distress, improved sleepand an improvement in quality of life. Unfortunately, and less fatigue. But there are no guarantees as to of what you will experience. Because of this, it is important that you carefully evaluate whether these potential risks outweigh the potential benefits of participating in therapy. Our first session two to three sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include include. Together we will identify your specific goals for therapy and will develop a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresprocedures or any other aspect of therapy, we should discuss them whenever they arise. If your you have doubts persistabout working with me, I will be happy to help you set up a meeting with find another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:therapist.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-3 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to charge a no-show fee of $50. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 120.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or over cash; I am not able to process credit card charges as payment. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 1-2 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, or longer if requested, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect $50 [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 120.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or over cash; I am not able to process credit card charges as payment. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statements. It varies depending on the personalities part because of the psychologist clearly defined rights and patient, responsibilities held by each person. This frame helps to create the safety to take risks and the particular problems support to become empowered to create change. As a client in psychotherapy, you hope have certain rights and responsibilities that are important for you to addressknow about. There are many different methods I may use also legal limitations to deal with those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work may include. At that point, we will include discuss your treatment goals and create a personalized, initial treatment plan to followplan, if you decide to continue with me for therapycontinue. You should evaluate this information along with as well as your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will typically involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hours’ notice, my policy is to collect the psychological services amount of your session [unless we both agree that you were unable to attend due to circumstances beyond your control]. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. FEES My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 180.00 and $250 for each subsequent psychotherapy session (either inis $150.00. The intake session may last longer than the typical 45-person 50 minute appointment. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment may be made with cash, check, or over credit card. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially There is no guarantee that entering treatment will reduce your symptoms or resolve your problems in the early phases of treatmentyour desired direction. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have any questions about my procedures, we should discuss them whenever they arise. If Psychotherapy sometimes involves consulting with other professionals, and if necessary, transferring your doubts persistcare to another professional to help you. For example, I do not do court work (such as, but not limited to testifying in divorce and custody disputes, injuries, lawsuits, etc.). So if you need these services I will give you referrals to forensic psychologists who specialize in these cases. SESSIONS I will usually schedule one 50-minute session per week at a time we agree on, although some sessions may be longer or more frequent. If they are shorter or longer for some reason, the fee will be happy adjusted according to help you set up a meeting with another mental health professional the quarter hour. The frequency can vary depending upon need, schedules and finances. PROFESSIONAL FEES The fee for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee regular individual therapy session is $395 for an initial evaluation lasting 90 minutes150 and I accept cash, check and $250 for each subsequent psychotherapy session credit cards (either in-person or over the telephone) lasting 45 minutesVISA & MasterCard). In addition to weekly appointments, I charge this same $250 per 45-minutes rate 150 an hour for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include psychological testing, report writing, telephone conversations or email responses lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. I request that you pay the whole fee at the end of each session, unless we have a written agreement otherwise. If you become involved in legal proceedings that require my participationpass a check on insufficient funds, you will be expected liable for the amount of the check and a service charge of twenty- five dollars ($25) for the first check and a thirty-five dollars ($35) service charge for each subsequent check passed on insufficient funds. CANCELLING APPOINTMENTS A scheduled appointment means that time has been reserved only for you. Although it is best to pay for any professional time I spend on your legal matterkeep regular appointments, even if there may be times when you cannot come in. You must call the request comes from another party, above phone number at least 24 hours in advance to cancel the same $250 per 45-minutes rateappointment. I If you do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been cancel more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment24 hours in advance, you will be scheduled charged the full normal fee for another initial evaluation that session. The exceptions to this policy are sudden major illnesses or accidents in which you may be involved. It is important to note that insurance companies do not pay for missed or late-cancelled appointment fees and the patient/responsible party is held fully accountable for this charge. MEDICARE I have opted-out of Medicare in accordance to the Balance Budget Act of 1997 (90 minutesSection 1802(b) and charged accordingly, of the Social Security Act). This law allows me to enter into a private contract with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesMedicare beneficiaries. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might haveare 65 or older, or will turn 65 within the next year, you may do so. However, will be aware that required to review and sign two copies of the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, preseparate MEDICARE OPT-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseOUT CLIENT AGREEMENT provided. I will provide you sign both and we will each keep a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:signed copy. CONTACTING ME

PSYCHOLOGICAL SERVICES. I am a Licensed Psychologist offering services in the field of psychology and psychotherapy. Having worked as a Psychologist for over 30 years, I have had vast experience in many areas of psychology. With my training and experience, I am able to offer you psychotherapy as an individual, couple, family, or group. I am also able to offer you consultation and referral services. There are many modalities of psychotherapy that I can offer you including: Cognitive Behavioral Therapy, Somatic Experiencing, Internal Family Systems, Imago Relationship, Emotion Focused Therapy, BrainSpotting, Hypnotherapy, EMDR, EFT, Touch, Interpersonal Neuropsychology, and many others. Please be advised that I do not prescribe medication; I can refer you to someone for medication such as your primary care doctor or a specialist. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems issues you hope to addressare experiencing. There are many different methods I may use to deal with those problemsbring healing, joy and health in your life. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have want to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, angeranger frustration, frustrationshame, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmenthelplessness or any other emotion. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. The mind and body are very connected. Therapy often leads to better relationships, solutions to specific problems, joy, freedom, growth, physical healing and significant reductions in feelings of distress, improved sleep, . Research has shown significant changes in brain function with psychotherapy. You will get to know not only your mind but also the intricate relationships between your mind and less fatigue. But there are no guarantees as to what you will experiencebody. Our first session few sessions will involve an evaluation of your needsneeds and goals; your hopes and dreams for therapy. By Usually after the end of the evaluationfirst session or two, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable enough working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves can involve a large commitment of time, money, money and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, in spite of my best efforts, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:professional.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described may involve a variety of activities designed to support you in general statementssuccessfully resolving the difficulties or conditions, which have led you to seek therapy. It varies depending on the personalities of the psychologist is a learning process and patientour therapy will be most successful if you engage openly and honestly in it, and the particular problems apply what you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on discovering in how you live your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homelife. Psychotherapy can have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, These feelings (and others which you may dislike) are often an essential element in successful therapy; such therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads can lead to better relationships, solutions to specific problems, and significant reductions increases in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapyone's well being. You should evaluate consider this information along with your own opinions about in choosing whether you feel comfortable working to work with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresapproach or other relevant matter, we should discuss please bring them whenever up as they arise. If your doubts reservation or objections persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciesAPPOINTMENTS/SESSIONS If we agree to begin psychotherapy, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)usually schedule appointments as agreed upon between us. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment hour is scheduled, you will be expected to pay for any professional it unless you provide 24 hours advance notice of cancellation. My fee is $120 for individual therapy and $140 per hour for couples counseling. CONTACTING ME Much of the time I spend on your legal matteram not immediately available by telephone. When I am unavailable, even if the request comes from another party, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge for time spent writing reports will make every effort to return your call promptly, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please leave in your message some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session feeavailable. I am not in-network with any insurance companiesmay also be reached by email at xxxxxx@xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. If you decide are unable to submit claims reach me and feel that you can’t wait for me to return your insurance company for reimbursement for any outcall, contact your family physician or the University of Neuropsychiatric Institute at 000-of000-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances0000. If your insurance company doesn’t reimburse youI will be unavailable for an extended time, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you with a superbill after each session name of a colleague to contact if necessary. CONFIDENTIALITY Professional ethics as well as the laws of the State of Utah protect the privacy of communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Unless you specifically request otherwise, your signature on this Agreement provides consent for those activities. I am required to disclose confidential information if certain specific conditions exist. These are detailed in the accompanying Notice of Policies and Practices to Protect the Privacy of Your Health Information. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. PROFESSIONAL RECORDS AND PATIENT RIGHTS HIPAA sets forth specific definitions and standards for Protected Health Information. These are detailed in the following information that you will need accompanying Notice of Policies and Practices to submit to your insurance company for reimbursement for any out-of-network benefits you might have:Protect the Privacy of Your Health Information.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your partthe problems that you hope to address. In order for the therapy addition, as I gather a more complete understanding of your unique needs as a client, I may from time to time consult with other professionals and/or recommend referrals to other medical, or mental health practitioners, if we decide that this will best serve you and our work together. All disclosures in this manner will require your consent. As a Psychologist Candidate my practice is under supervision of Xxxxxx Xxxxxx, PsyD, License number PSY 3201. Clinical information will be most successful, you will have discussed with him and he is legally bound to work on things we talk about both during our sessions and at homekeep information confidential. Psychotherapy can have benefits and risks. Because Since therapy often involves may involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itengage in this service. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and thoughts about the issues that you have brought into therapy and we can then discuss a treatment plan to follow, if you decide to continue with me for therapydirection. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It The therapy experience varies depending on the personalities personality of both the psychologist therapist and patient, the client and the particular problems you hope which the client brings to addresstreatment. There are many a number of different methods I theoretical approaches in the field of psychotherapy. All are designed to address the problems that you are coming here to work on, but therapy may use look very different from one approach to deal with those problemsanother. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Voicing opinions, thoughts, and feelings honestly and openly to your therapist, including about the therapeutic process, is an important part of the overall treatment outcome. Psychotherapy and cognitive behavioral therapy (CBT) can have benefits and risks. Because Since therapy involves addressing difficult and often involves discussing unpleasant aspects fearful issues, during the course of your life, therapy you may experience uncomfortable feelings like feelings, such as guilt, sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentetc. On the other hand, psychotherapy CBT in particular has also been shown consistently demonstrated to have benefits for people who go through it. Therapy often leads be helpful in the significant reduction of negative experiences such as distress and sadness, to better relationships, solutions enable people to specific problems, significant reductions in feelings of distress, improved sleepcontrol self-destructive behaviors, and less fatigue. But there are no guarantees as to what you will experienceoverall increase quality of life and one’s satisfaction in day to day living. Our first session few sessions will involve an evaluation of your needs. By the end of the this evaluation, I will be able to offer you some first impressions of what our your work will include and a treatment plan pertaining to follow, if the problems you decide to continue with me for therapydiscussed. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and and, if so, I will give you referrals to other practitioners who whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions reduction in feelings of distress. There are, improved sleepof course, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, time and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresapproach, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health Counseling Center professional for a second opinion. Please note When the treatment needs of a prospective client exceed our scope of practice, every effort will be made to identify appropriate resources in the Chicago area. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable my telephone is answered by voice mail. 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 unable to reach me and feel that you cannot wait for me to return your call, you may find it helpful to contact the psychological services I provide are not for emergency situations. For emergencies, call 911 crisis hotline at Northwestern Memorial Hospital (312-926-8100) or you can go to the nearest emergency roomroom and ask for the psychiatrist on call. FEES My fee is $395 If I will be unavailable for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following name of a colleague to contact, if necessary. LIMITS OF CONFIDENTIALITY In accordance with professional ethics and Illinois law, the information revealed in psychotherapy is confidential and will not be revealed to anyone without your written permission, except as required by law. Illinois law requires that I make appropriate reports if you are suicidal or homicidal, or if any child or elder adult has been abused or neglected. I may occasionally find it helpful to consult with other health and mental health professionals about a case. When appropriate, this may include the Counseling Center’s consulting psychiatrist. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you will need may have now or in the future. COUNSELING CENTER INFORMATION SHEET Name: Address: City/Zip: Cell Phone: Other Phone: Date of Birth: E-mail Address: I hereby authorize Counseling Center staff members to submit contact me using the above E-mail address: Signature Emergency Contact Information: Name: Relation to your insurance company for reimbursement for any out-of-network benefits you might have:you: Phone Number: YOUR SIGNATURE HERE INDICATES THAT YOU HAVE READ THE PSYCHOTHERAPIST – CLIENT AGREEMENT AND AGREE TO ITS TERMS.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 50 minutes (individual) or 80 mins (EMDR, couple) in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, I ask that you provide me with advanced notice. If you miss a session without canceling, or cancel later than 8am on the psychological services day of your appointment, my policy is to collect a $25.00 fee (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I provide will try to find another time to reschedule the appointment. You are not allowed two “no show” appointments, after which we will discuss transferring you to another clinician. In addition, you are responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My The standard fee for each session is $395 for an initial evaluation lasting 90 minutes200 (individual, and EMDR), or $250 (couple) unless otherwise agreed-upon. You are responsible for each subsequent psychotherapy paying at the time of your session (either in-person unless prior arrangements have been made. Payment can be made by check, cash, or over credit card. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another partyparty compels me to testify. INSURANCE All insurance information is handled by Psychotherapy Billing Services, at LLC. This company adheres to the same $250 per 45HIPAA practices used at this office and all information provided related to billing will be handled in a professional and confidential manner. For any questions related to insurance billing, contact Xxxxx Xxxxxxx at (541) 343-minutes rate8122 ext. 4. PROFESSIONAL RECORDS I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I do not charge keep brief records noting that you were here, your reasons for time spent writing reports seeking therapy, the goals and progress notes as per the standard routine of my care of you. we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, any correspondence between us, records I also do not charge for any time I may spend collaborating with your receive from other providers, copies of records I send to others, and your billing records. From time Except in unusual circumstances that involve danger to timeyourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I may institute fee increases and these will be discussed and agreed upon ahead of time recommend that you initially review them with a new Treatment Contractme, or have them forwarded to another mental health professional to discuss the contents. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentI refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will be scheduled for another initial evaluation (90 minutes) and charged accordingly, discuss with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying you upon your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance coversrequest. You are responsible for checking also have the right to request that a copy of your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely file be responsible for the full session fee in these instances. If made available to any other health care provider at your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It ; it varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. My primary methods are rooted in my ABPP Board Certification in Behavioral and Cognitive Psychology (awarded in 2014) as well as being a Founding Fellow in the Academy of Cognitive Therapy (awarded in 1999). I will often utilize other Evidence-based procedures. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about about, both during our sessions and at home. home Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have many health benefits for people who go through it. Therapy Psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. These aforementioned concerns, improved sleepif not treated, and less fatiguehave often been correlated with negative health concerns. But Nevertheless, there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needsCONTACT I am often not immediately available by telephone nor email. By the end of the evaluationWhile I am usually nearby my home-office telephone, I will be able to offer not answer not answer the phone when I am with a client, so please leave me a voice message on 000-000-0000. If you some first impressions of what our work will include and send an email, please still leave me a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe voice message so that I am not the right therapist for you and if socertain to see your transmission. Please note, I would prefer that you do not send an email containing personal NOR urgent information. I will give make every effort to return your call on the same day you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectmake it. If you have questions about my proceduresdo not hear from me in 24 hours, we should discuss them whenever they ariseplease try calling me again. If your doubts persistyou are difficult to reach, please inform me os times when you will be available, as well as a telephone number. Although xxxxxxxx@xxxxxxxxxxxx.xxx. is a Hush mail encrypted, HIPPA compliant service, I would prefer that confidential information is conveyed over my land line office number 000-000-0000, sent to my land line facsimile 000-000-0000, or mailed directly to my office, 000 Xxxx Xxxxxx Xxxx, Xxxxxxxxxx, XX 00000-0000. My preferred general, NOT HIPPA compliant, email address is xx.xxxxxxxx@xxxxx.xxx If you are an established patient of mine, I do have a digital pager 000-000-0000 near me 24/7 for emergencies. However, please leave a message on my office line first, leaving your telephone number, as it is not unusual for me to receive only 9 digits on my pager You will be happy need to help you set up a meeting with another mental health professional dial 000-000-0000 and wait for a second opinionbeep, which is generally preceded by instructions, then digitally enter a telephone number where you can be reached before hanging up. Please note that However if you do not hear back from me within a few minutes after you digitally entered in the psychological services I provide are not for emergency situations. For emergencies, number to reach you then IMMEDIATELY call 911 or go proceed to the nearest emergency roomroom and ask for the psychologist/psychiatrist on call. FEES My fee is $395 If I will be unavailable for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need name of a colleague to submit to your insurance company for reimbursement for any outcontact, if necessary. -of-network benefits you might have:

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods also legal limitations to those rights that you should be aware of. As your therapist, I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. However, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 1-­‐3 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS, CANCELLATION, AND NO-­‐SHOW POLICY Appointments will ordinarily be 45-­‐50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24-­‐hour notice, my policy is to collect the full session amount [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still end on time. If you have no-­‐showed and have not scheduled an appointment after 30 days, I provide will assume you are ending treatment and may close your file at that time. I will consider you no longer an active client if 1) 60 days have passed, 2) you do not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for have an initial evaluation lasting 90 minutesappointment with me, and 3) you have not responded to my three attempts to reach you via phone or email. You may contact me to set up an appointment to become an active client again. PROFESSIONAL FEES The 20-­‐minute consult is free of charge whether by phone or in person. The fees per session are as follows: neurofeedback -­‐ $250 125, psychotherapy -­‐ $175, neurofeedback and psychotherapy combined – $250. You are responsible for each subsequent psychotherapy paying at the time of your session (either in-person unless we have discussed prior arrangements via cash, check, credit card, or over automatic bank payment processing. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee incurred. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, I charge this same $250 per 45-minutes rate amount on a prorated basis for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsa confidential exploration, discussion and mutually agreed upon plan for change. It varies depending on You and the personalities of therapist will define the psychologist and patientproblem, possible causes, and several treatment approaches. The risks of treatment will be discussed. You and the particular problems you hope to address. There are many different methods I may use to deal with those problemstherapist will discuss what helps solve the challenge and what isn’t working. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very is active effort on your part, often with homework assignments to clarify what is discussed during the office sessions. In order Psychotherapy is different from psychological evaluation. Whereas psychotherapy is organized to formulate a treatment plan in the best interests of the client, psychological evaluation often includes assessment and psychological testing. Another key difference between psychotherapy and psychological evaluation is that the psychologist advocates for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homeclient while the evaluator is impartial. Psychotherapy can have has benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specificallyHowever, therapy might cause you to research on the efficacy of psychotherapy outweighs the temporary feelings of distress one may experience increased sleepiness and fatigue, especially in the early phases of treatmentwhile working on emotional challenges. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy Psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions reduction in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will may experience. Our The first session few sessions will involve an evaluation of be assessment and treatment planning. During this time, you and the therapist decide if they are the best person to provide the service that you need in order to meet your needstreatment goals. By the end of these first few sessions, the evaluation, I therapist will be able to offer you some first preliminary impressions of your problem, what our the work will include include, and a treatment plan and treatment modality to follow, decide if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtherapist. Therapy involves a large commitment of time, money, money and energy, energy so you should need to be very careful about the therapist you selectselection of your therapist. If you have questions about my the therapist’s procedures, we should discuss please bring them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of metheir attention. If you become involved in legal proceedings that require my participationwant a second opinion regarding your diagnosis or treatment, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I therapist will provide you a superbill after with names of other professionals. Once psychotherapy has begun, you and the therapist determine the intervals between sessions that best support the treatment plan. Sessions are 50 minutes, unless you schedule additional time. Your commitment to the therapeutic process is crucial and is demonstrated by your understanding and written agreement to the following. Please initial by each session with item representing your having read, understood, and agreed to the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:content therein.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems concerns you hope wish us to addressaddress together. There are many different methods I may use to deal with those problemsthe issues you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for You will make the therapy to be most successful, best progress if you will have to work actively on things we talk about address, both during in our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are There can be no guarantees as to guarantee of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. MEETINGS I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week or every other week at a time we agree upon, although some sessions may be longer or more or less frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or unless I can fill the open slot with another patient. An appointment scheduled for Monday must be cancelled by 5 PM the preceding Thursday to avoid having to pay for the session. Please note that the psychological services I Insurance companies do not provide are not reimbursement for emergency situationscancelled sessions or missed appointments. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My fee for a standard 50-minute session is $395 for an initial evaluation lasting 90 minutes180.00. In addition to appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate amount for other professional services you may need, though although I will prorate break down the cost into tenths of an hour if I work for periods of less than 45 minutes in increments of 15 50 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services might include report writing, telephone conversations or email responses lasting longer than 15 five minutes, email exchanges, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you or your representative may request of me. At the time of scheduling your first appointment, you will be asked to pay for the first session to hold your spot, using a secure, HIPAA-compliant credit card processing service called Ivy Pay. With your consent, you will receive a text message from Xxx, asking you to enter your credit card information and make your first payment. This is a one-time set up. Thereafter, each time a fee is generated, it will be charged to this credit card using Ivy. (If you prefer, you may pay for in-person services with cash or check.) If your card is charged for a session or for one of the other services described above, you will receive a text message notifying you that a fee has been processed. More detailed information about Ivy Pay is included later in this Agreement. If you become involved in legal proceedings that require my participation, you will be expected to pay for any my professional time, including preparation and transportation time I spend on your legal mattercosts, even if the request comes from I am called to testify by another party, at . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports complexity and progress notes as per the standard routine liability of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I may institute fee increases charge $225 per hour for preparation for and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with participation in any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance coverslegal proceeding. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for find more information about court involvement below in the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:section entitled Limits on Confidentiality.

PSYCHOLOGICAL SERVICES. Psychotherapy is Psychological services – psychotherapy and psychological assessment – are not easily described in general statements. It varies They vary depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different conventional and emerging methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is Some of these may involve my touching you by, for example, pressing down on your extended arm while you state something about your problem. Psychological services are not like a medical doctor visitservices. Instead, it calls they call for a very active effort on your part. In order for the therapy services to be most successful, you will may have to work on things we talk about both during our sessions and at home. Psychotherapy Psychological services can have benefits and risks. Because Since therapy and assessment often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has these psychological services have also been shown to have benefits for people who go through itmany benefits. Therapy and/or psychological assessment often leads lead to diagnoses, better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve The purpose of an evaluation of initial intake is to evaluate your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapypsychological services. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves Psychological services involve a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note 0000 Xxxxxx Xxxxxxxx Xxxx, Xxxxx X Telephone (000) 000-0000 San Diego, California 92129 xxxxxxx@xxxxxxxxxxxxxxxx.xxx MEETINGS I normally conduct an evaluation that will last 1 to 1.5 hours. During this time, we can both decide if I am the psychological best person to provide the services that you need in order to meet your treatment goals. If psychotherapy is begun, I provide are not for emergency situations. For emergencies, call 911 or go will usually schedule one 45 to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy 50-minute session (either in-person one appointment) per week at a time we agree on, although some sessions may be longer or over the telephone) lasting 45 minutesmore frequent. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment hour is scheduled, you will be expected to pay for any professional time I spend on the appointment ($200) unless you provide one business day advance notice of cancellation (usually 24 hours, excepting Monday appointments), unless we both agree that you were unable to attend due to critical circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol. I It is important to note that insurance companies do not charge provide reimbursement for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractcancelled sessions. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse youis possible, I am not responsible for refunding you any payment you expected will try to be reimbursed or otherwise. I will provide you a superbill after each session with find another time to reschedule the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:appointment.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in therapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. In therapy, there are both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness; because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. Psychotherapy is not like a medical doctor visitBut, there are no guarantees about what will happen. Instead, it calls for Therapy requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homediscuss outside of sessions. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. INDIVIDUAL THERAPY SESSIONS Our first initial session will involve an evaluation of defining your needsneeds and goals for us working together. By the end of the evaluationthis assessment of your needs, we will both have a clear picture of what we can benefit from working on together; and I will be able to offer you some first initial impressions of what our work might include. At that point, we will include and a discuss your treatment plan to follow, if you decide to continue with me goals. We can collaborate on which objectives will be the most beneficial for therapyyou. The objectives for reaching your goals can be adjusted at any time during our sessions. You should have the right to evaluate this information along with information, and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, please feel free to bring them up so we should can discuss them whenever they arise. If your doubts in our working together persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not TELEMENTALHEALTH COUNSELING SERVICES My telephone and connection is secured for emergency situationsyour privacy during a telephone session. For emergenciesonline video sessions, call 911 I use a HIPPA-compliant platform for your confidentiality. APPOINTMENTS Individual appointments will ordinarily be 30 minutes in duration, once per week, at a time we agree on--although some sessions may be more or go less frequent as needed, or based on what we agree upon together. Once we have had our first session together, and this agreement is signed, if you find you need to cancel or reschedule a session, my policy is to have 24-hours notice. If you miss a session without canceling, or cancel or reschedule with less than a 24-hour notice, my policy is to collect the nearest emergency roomamount of your payment for your session. This is in place due to working by appointment only, if someone may have wanted to come in for an appointment, or is on my waiting list that may be in need of an appointment time. The fee for canceling without 24-hours notice, rescheduling, or not showing for your appointment is your regular session fee. If paying by credit card, the aforementioned fee will be automatically charged the day of your session time. [unless we both agree that you were unable to attend due to circumstances beyond your control]. If you are able to cancel prior to 24-hours of your scheduled session time, and we are able to communicate and reschedule your session within the same week, you will then not lose your session, nor your fee for your session. If we have a late start to your appointment, we will still need to end on time to accommodate for an appointment time following yours. PROFESSIONAL FEES My For individual sessions, in-person, by secure video, or by telephone, the standard fee for each session is $395 for an initial evaluation lasting 90 minutes95.00 per 50 minute session. If we find more time is needed at the end of your hour session, and $250 for each subsequent psychotherapy session (either in-person or over I can prorate the telephone) lasting 45 minutesadditional time if it is open to do so. Payment is due at the time of your session. I accept Venmo, PayPal, or Zelle bank transfer. As mentioned above, in addition to your appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for additional sessions time, or other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings, or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. The psychological services that are provided at Xxxxx Creek Psychology include psychotherapy as well as psychological and neuropsychological testing. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Psychotherapy and psychological/neuropsychological assessment can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy and assessment has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Assessment can lead to a greater understanding of the child’s problems and lead to recommendations to improve functioning at home, improved sleepschool, and less fatigueor socially. But there are no guarantees as to of what you will experience. Our For psychotherapy, our first session few sessions will involve an evaluation assessment of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting obtain an appropriate consultation with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of meprofessional. If you become involved are unable to keep appointments and I do not hear back from you for one month, this will constitute a formal ending of our work together. Forensic Issues I do not serve as an advocate for clients obtaining or keeping disability or in legal matters such as lawsuits, custody evaluations, divorce proceedings that require my participation, you or criminal cases. Information will be released with your written permission and direction as determined appropriate for a situation. You will be expected to pay for any all of my professional time, including preparation and transportation costs, if I am court ordered to participate in a specific case. No insurance reimbursement will be applicable to that time and my fees for legal services will be greater than customary fees. Sessions For psychotherapy, I spend on normally conduct an assessment that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you or your legal matterchild need in order to meet your treatment goals. Each session lasts from 45 to 60 minutes. Sessions are typically scheduled once per week, even if although in some situations we may meet more or less frequently. My practice provides outpatient services and is set up to accommodate individuals who are reasonably safe and resourceful. My practice, therefore, may not always be appropriate for clients who need more intensive and frequent contact. If this is found to be the request comes from another partycase, at I will provide recommendations and referrals for a better fit to meet your needs. Contacting Me Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office regular hours, I probably will not answer the same $250 per 45-minutes ratephone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I do not charge will make every effort to return your call within 24 to 48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If I will be unavailable for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to an extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with have a new Treatment Contract. If it has been more than one year since our last appointment, then colleague available for you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In additionto contact, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesnecessary. If you decide are unable to submit claims to reach me and have a mental health emergency, contact your insurance company for reimbursement for any out-of-network benefits you might havefamily physician, you may do so. Howeveror call 911, be aware that or call the services provided will still be charged to you, not your insurance company, nearest emergency room and you are responsible ask for the full payment. I have no role in deciding what your insurance coverspsychologist or psychiatrist on-call. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours can also contact one of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company mental health emergency resources: Ridgeview Institute at 000-000-0000, Peachford Hospital at 000-000-0000, or SummitRidge Center for reimbursement for any outPsychiatry and Addictions at 000-of000-network benefits you might have:0000.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Your therapist has corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our outside of sessions. The first sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first initial impressions of what our work might include. At that point, you and your therapist will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selecttherapist. If you have questions about my procedures, we should please discuss them whenever they arise. If your doubts persist, I we will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that Your participation in the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee counseling process is $395 for an initial evaluation lasting 90 minutesvoluntary, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service withdraw at any time. All counseling services will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations discontinued at your request or email responses lasting longer than 15 minutes, when you and the time spent performing therapist have determined that your goals have been met and your problems resolved. You have the right to ask questions about treatment at any other service you may request of metime. If you become are dissatisfied, you have the right to talk to the therapist that works with you about your dissatisfaction, and if problems cannot be resolved, you have the right to talk to Xxxxxxxxx Xxxxxx, Program Director, at 000-000-0000. You will be involved in legal proceedings that require my participationdeveloping a treatment plan and participating in counseling activities. You have the right to be informed about specific services and procedures, you including information about risks, benefits, and alternatives to each activity proposed for treatment. Appointments will ordinarily be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-50 minutes ratein duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. I The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide me with 24-hours notice. It is important to note that insurance companies do not charge provide reimbursement for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractcancelled sessions. If it has been more than one year since our last is possible, we will try to find another time to reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit coming to your insurance company for reimbursement for any out-of-network benefits you might have:session on time.

PSYCHOLOGICAL SERVICES. Psychotherapy is and psychological evaluations are not easily described in general statements. It varies They vary depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your graduate clinician or evaluator may use to deal with those problemsthe problems that you hope to address. Psychotherapy is and assessments are not like a medical doctor visitvisits. Instead, it calls They call for a very active effort on your part. In order for the therapy them to be most successful, you will have to work on things we talk about that are discussed both during our sessions and throughout the week at home. Also, you will have to be honest about the subjects we talk about and put forth good effort on the tests you are asked to complete as part of therapy or your evaluation. Therapy and evaluations involve a commitment of time, money, and energy. Psychotherapy and psychological evaluations can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Assessment often leads to a better understanding of yourself, improved sleepyour relationships, solutions to specific problems, and less fatiguesignificant reduction in feelings of distress. But However, there are no guarantees as to of what you will experienceexperience when you take part in therapy or a psychological evaluation. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. PROFESSIONAL FEES For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either sessions completed in-person or over telehealth, clients will be expected to pay for each session at the telephone) lasting 45 minutestime it is held, unless other arrangements have been determined. I charge this same $250 Therapy clients are charged per 45-minutes rate 50 minute session. Typically, clients at AUPSC are seen once a week for other professional services you may needone 50 minute session. In the event that a client and clinician decide to meet more than once a week, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service client will be charged the agreed upon therapy fee for 15 minutes whereas 23 minutes of service each time that they meet. If a client requests a therapy session longer than 50 minutes, then they will be charged billed for the extended time in 15 minute increments. To maintain active status as a client at AUPSC, payment must be made at the time services are rendered. After 2 consecutive sessions of nonpayment, clients will need to contact the clinic director to reinitiate services. Therapy fees in person and via telehealth are determined using a sliding scale. In order to be eligible for the sliding scale, clients will be asked to provide proof of income at their first visit. Examples of proof of income include one of the following: the most recent tax return, disability letter, food stamp letter, or unemployment benefit letter. Although names must be visible on the proof of income document to confirm eligibility, please mark through social security numbers so that they are not visible. Students qualify for $30 minutesper session fee for individual therapy for themselves. Eligibility for the sliding scale will be re-verified annually. In the event that a client does not wish to provide documentation of annual family income, the highest income bracket will be assumed. If a financial crisis exists (for example, loss of job or loss of housing) that causes a client to be unable to pay their weekly therapy fee, the clinician can discuss the need for a fee reduction with their licensed clinical supervisor and the Clinic Director. With written documentation of financial crisis, the client’s therapy fee may be reduced by $15 per session for up to 10 sessions. Telephone calls to clinicians are not an effective substitute for regular therapy sessions and should be limited to emergencies. Telephone calls longer than 5 minutes will be billed at the regular session fee in 15 minute increments. In the event that consultation services are required (for example, with school professionals, psychiatrists, primary care physicians, or previous treatment providers), the client will be billed at the regular session fee in 15 minute increments. Other professional services include telephone conversations such as reviewing previous treatment records or email responses lasting longer than conducting school observations will also be billed at the regular session fee (in 15 minutesminute increments). If treatment records are requested, a fee of $20 may be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the time spent performing any other service you may request of merequested documents. If you become involved in legal proceedings that require my your graduate clinician or your graduate clinician’s supervisor’s participation, you will be expected to pay for any all of your graduate clinician’s and your graduate clinician’s supervisor’s professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from your graduate clinician or your graduate clinician’s supervisor is called to testify by another party, . Full psychological evaluations have a preset charge of $650. Half of this fee is due at the same initial assessment session, and the other half is due at the feedback session. The assessment fee includes all interviews, all assessment measures, all consultations, one written report, and one feedback session. This fee also includes AUPSC mailing or faxing the written report to one professional of the client’s choice. If additional reports are requested, a fee of $250 per 45-minutes rate20 may be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the requested documents. I In the event that a full psychological evaluation is not required, a reduced fee can be determined by the Clinic Director on a case by case basis. Assessment measures that are administered as part of therapy without a formal report will be of no additional charge to the normal therapy fee. Assessment costs do not charge for time spent writing reports exceed $650 and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed determined by the extent of testing requested by the client. Therapy clients will be charged up to their regular session fee for missed appointments and agreed upon ahead of time with a new Treatment Contractfor appointments canceled or rescheduled less than 24 hours in advance. Assessment clients will be charged $60 for missed appointments and for appointments canceled or rescheduled less than 24 hours in advance. After 3 missed appointments in one semester, clients will be considered inactive and will need to contact the Clinic Director to reinitiate services. If it has been clients are more than one year since our last appointment15 minutes late for a session, then you the clinician and supervisor reserve the right to reschedule the appointment and charge up to the session fee. Clients with outstanding balances will receive a financial summary statement at the end of each month, which will detail all transactions that are made. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, AUPSC retains the option of using legal means to secure the payment. After two consecutive sessions of nonpayment, clients will need approval by the clinic director to re-initiate services at my current standard fee services. This may involve hiring a collection agency or going through small claims court which may be higher than the fee you were previously payingwill require AUPSC to disclose otherwise confidential information. In additionmost collection situations, if it has been more than one year since our last appointmentthe only information AUPSC releases regarding a client’s treatment is the client’s name, you the nature of services provided, and the amount due. If such legal action is necessary, its costs will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterincluded in the claim. INSURANCE REIMBURSEMENT You Because AUPSC is a training clinic and graduate students who are responsible not licensed clinical psychologists provide the services, third party health insurance will NOT pay for paying your full session feethe services rendered at AUPSC. I am not in-network with any The only exceptions to this situation are the cases where the Alabama Department of Human Resources or local school systems pays for services rendered at AUPSC. Thus, AUPSC will NOT file insurance companiesforms. If you decide wish to submit claims to your insurance company for pursue reimbursement for any out-of-network benefits the services you might havehave received at AUPSC, we will provide you may do sowith a bill that lists the services provided. However, be aware that the services provided will still be charged to you, you (not your insurance company, and you ) are responsible for full payment at the full paymenttime services are rendered, unless alternate arrangements have been made in advance. I have no role in deciding It is very important that you find out exactly what mental health services your insurance policy covers. You are responsible for checking If you have insurance that covers mental health services, AUPSC will be happy to refer you to a licensed therapist who might be covered by your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancescompany. If your insurance company doesn’t reimburse youservices are being paid for by the Alabama Department of Human Resources or a school system, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session your contract with the following Alabama Department of Human Resources or your school system requires that AUPSC provide it with information relevant to the services that are provided to you. AUPSC is also required to provide information regarding clinical diagnosis, when a diagnosis is assigned. Sometimes AUPSC is required to provide additional clinical information, such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, AUPSC will ask that you sign an Authorization Form to Release/Obtain Information in order to release information about you that is necessary for the purpose requested. This information will need become part of the Alabama Department of Human Resources or the school systems records and might be stored in a computer. Though the Alabama Department of Human Resources and schools claim to submit keep such information confidential, AUPSC has no control over what they do with it once it is in their hands. If you refuse to your insurance company allow AUPSC to release information relevant to the services that are provided to you by AUPSC, then the Alabama Department of Human Resources or the school system will not pay for reimbursement for any out-of-network benefits services provided to you might have:by AUPSC.

PSYCHOLOGICAL SERVICES. Psychotherapy Psychological treatment is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use that can be used to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, in that it calls for a very active effort on your part. In order for the therapy to be most successful, you will may have to work on things we talk about both during our sessions and at home. Psychotherapy Psychological treatment can have both benefits and risks. Because therapy Treatment often leads to significant reductions in feelings of distress, as well as improvements in specific problems and relationships. But there are no guarantees of what you will experience, and it is possible that you may not become happier. Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially helplessness in the early phases course of treatment. On the In some cases there may be increased conflict or other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better undesirable changes in relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session initial discussions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to followinclude, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about judgment of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting secure an appropriate consultation with another mental health professional if you desire one. For reasons of professional ethics, I generally avoid multiple relationships with clients, such as doing assessments (beyond those needed for treatment) or forensic services with therapy clients. MEETINGS I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the right person to provide the services that you need. If treatment is begun, I will usually schedule one 45-minute session per week at a second opinionmutually agreed time, although sometimes sessions may be longer or scheduled at other intervals. Please As much as possible, I expect all matters, including financial, to be discussed during sessions. Once an appointment is scheduled, you will be expected to pay for it unless you call or write me (not text) at least 24 hours in advance to cancel, unless we both agree that you were unable to attend and unable to provide 24 hours notice due to circumstances beyond your control. In the latter case there will be a $20 late cancellation fee. Otherwise, if you miss or cancel an appointment with less than 24 hours advance notice, you will need to pay for the appointment in full (not just your insurance co-payment). It is important to note that the psychological services I insurance companies almost never provide are not reimbursement for emergency situationscancelled sessions. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My usual fee is $395 120 for an initial evaluation lasting 90 minutesa 45-minute individual psychotherapy, and $250 for each subsequent psychotherapy session (either in-person hypnosis or over the telephone) lasting 45 minutescouple/family session. In addition to regular appointments, I charge this same $250 per 45-minutes rate 120/hr on a prorated basis for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutessuch as psychological testing, rounded to the nearest 15-minute increment (e.g.preparing letters or other documents, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 10 minutes, meetings or consultations which you have authorized, review or preparation of records or treatment summaries, and the time spent performing any other service you may request of me. A discounted fee may apply if an insurance plan or Employee Assistance Program in which I participate covers the services, or if you pay in full at a session and no billing is done. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. I will not voluntarily appear in court on your behalf unless we have discussed the matter thoroughly, and we both agree that the court appearance will not interfere with the treatment relationship. Because of the difficulties of legal involvement, I charge $200 per hour for participation in any legal proceeding, and I generally require payment of all or part of such fees in advance. I can provide you with a detailed schedule of my professional fees in legal matters. BILLING AND PAYMENTS You will be expected to pay for each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not You agree to pay the full charge for time spent writing reports missed appointments, not just the copayment or coinsurance, unless you cancel 24 hours in advance or are unable to cancel 24 hours in advance. If your account has not been paid for more than 60 days and progress notes as per the standard routine of my care of you. I also do arrangements for payment have not charge for any time I may spend collaborating with your other providers. From time to timebeen agreed upon, I have the option of using legal means to secure the payment. This may institute fee increases and these involve using a collection agency or small claims court which will require me to disclose otherwise confidential information. If such legal action is necessary, its costs will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than included in the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterclaim. INSURANCE REIMBURSEMENT You are responsible In order for paying us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your full session fee. I am not in-network with any insurance companiestreatment. If you decide have a health insurance policy, it is likely to submit claims provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coveragepayment of my fees, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), unless this is prohibited by a contract between me and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse youor other healthcare organization that covers your behavioral-health benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseshould call your plan and inquire. Of course, I will provide you a superbill after each session with whatever information I can based on my experience and will help you in understanding the following information that you will need to submit to receive from your insurance company. I may be willing to call the company for reimbursement for any out-of-network benefits on your behalf. However, because of the complexity of insurance claim processing, you might have:cannot assume that my understanding of your coverage will always be correct.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specificallyTherefore, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentsometimes people get “worse” before they get better. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluationthis time, I will be able to offer you some first impressions of what our work will include and a treatment plan to followgoals, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresthe process, we should discuss them whenever they arise. If your doubts persistMEETINGS When psychotherapy is begun, I will usually schedule one 45/50-minute session per week at a time we agree on, although some sessions may be happy longer or more frequent. Once an appointment hour is scheduled, you will be expected to help pay for it unless you set up a meeting with another mental health professional for a second opinionprovide 24 hours, business days (Monday-Friday) advance notice of cancellation (except in case of an emergency – such as hospitalization, severe illness, inclement weather, or death). Please It is important to note that insurance companies do not provide reimbursement for cancelled or missed appointments. In such a case, you will be responsible for full payment of the psychological services I provide are not for emergency situationssession at the hourly rate. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My fee per therapy hour (45/50 minutes) is $395 standard for an initial evaluation lasting 90 minutesindividuals and slightly more for couples. In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate by the hour for other professional services you may need, though I will prorate break down the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)a therapy hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be charged for my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge extra per hour for preparation and attendance at any legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by my voice mail that I monitor frequently. 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. In extreme emergencies, you can call Xxxxx Hill Respond Program (919-250-7000), or you can try me at my home number. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” or Protected Health Information in my Notice of Policies and Practices to Protect the Privacy of Your Health Information). . • You should be aware that I share facilities with other mental health professionals and that I contract with administrative staff with whom I need to share protected information for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All professionals are bound by the same rules of confidentiality and have been given training about protecting your privacy. They have agreed not to release any information outside of the practice without permission. • At times I may contract with other associates for professional services. If so, as required by HIPAA, I will have a formal business associate contract with these businesses (ex. administrative assistant, computer assistant) in which they promise to maintain the confidentiality of this data. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If I believe that a patient presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, the psychotherapist-patient privilege law protects such information. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, provide a copy of the patient’s record to the patient’s employer or the North Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm. I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I have cause to suspect that a child under 18 is abused or neglected, or if I have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that I file a report with the County Director of Social Services. Once such a report is filed, I may be required to provide additional information. • If I believe that a patient presents an imminent danger to the health and safety of another, I may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about you in two categories within your file. One set constitutes your Clinical Record. It basically includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record and they are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization (on a special form). Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form of Privacy Practices, and my privacy policies and procedures. MINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this may require that some private information be shared with parents. For children under 18, I share general information with parents about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do Payment schedules for other professional services will be agreed to when they are requested. If your personal account has not charge been paid for time spent writing reports more than 60 days and progress notes as per the standard routine of my care of you. I also do arrangements for payment have not charge for any time I may spend collaborating with your other providers. From time to timebeen agreed upon, I may institute have the option of securing payment by other means. Overdue accounts are subject to interest. There is a fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterreturned checks. INSURANCE REIMBURSEMENT You are responsible In order for paying us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your full session fee. I am not in-network with any insurance companiestreatment. If you decide have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to submit claims to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the full paymentsection in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. 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. 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 mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no role control over what they do with it once it is in deciding what their hands. In some cases, they may share the information with a national medical information databank. By signing this Agreement, you agree that I can provide requested information to your insurance coverscarrier. You are responsible for checking Once we have all of the information about your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you we will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected discuss what we can expect to be reimbursed or otherwise. I will provide you a superbill after each session accomplish with the following information benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you will need always have the right to submit pay for my services yourself to your insurance company for reimbursement for any out-of-network benefits you might have:avoid the problems described above (unless prohibited by contract). YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE OF PRIVACY PRACTICES FORM DESCRIBED ABOVE. Rev. 05/09 Patient/Guardian Signature Date I have received a copy of the current fee schedule

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of $50.00 [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above (Please review the No Show No Cancellation Policy). If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergenciesPROFESSIONAL FEES The standard fee for the initial intake is $105.00 (Individual) and each subsequent session is $85.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment can be made by check, call 911 cash or go credit card (credit card payments must be made on our website prior to the nearest emergency roomsession). FEES My Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is and psychological evaluations are not easily described in general statements. It varies They vary depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your graduate clinician or evaluator may use to deal with those problemsthe problems that you hope to address. Psychotherapy is and assessments are not like a medical doctor visitvisits. Instead, it calls They call for a very active effort on your part. In order for the therapy them to be most successful, you will have to work on things we talk about that are discussed both during our sessions and throughout the week at home. Also, you will have to be honest about the subjects we talk about and put forth good effort on the tests you are asked to complete as part of therapy or your evaluation. Therapy and evaluations involve a commitment of time, money, and energy. Psychotherapy and psychological evaluations can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Assessment often leads to a better understanding of yourself, improved sleepyour relationships, solutions to specific problems, and less fatiguesignificant reduction in feelings of distress. But However, there are no guarantees as to of what you will experienceexperience when you take part in therapy or a psychological evaluation. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. PROFESSIONAL FEES For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either sessions completed in-person or over telehealth, clients will be expected to pay for each session at the telephone) lasting 45 minutestime it is held, unless other arrangements have been determined. I charge this same $250 Therapy clients are charged per 4550-minutes rate minute session. Typically, clients at AUPSC are seen once a week for other professional services you may needone 50-minute session. In the event that a client and clinician decide to meet more than once a week, though I the client will prorate be charged the cost if I work agreed upon therapy fee for periods of less each time that they meet. If a client requests a therapy session longer than 45 minutes in increments of 15 50 minutes, rounded to then they will be billed for the nearest extended time in 15-minute increment (e.g.increments. To maintain active status as a client at AUPSC, 22 minutes payment must be made at the time services are rendered. After 2 consecutive sessions of service nonpayment, clients will need to contact the clinic director to reinitiate services. Therapy fees in person and via telehealth are determined using a sliding scale. In order to be eligible for the sliding scale, clients will be charged asked to provide proof of income at their first visit. Examples of proof of income include one of the following: the most recent tax return, disability letter, food stamp letter, or unemployment benefit letter. Although names must be visible on the proof of income document to confirm eligibility, please mark through social security numbers so that they are not visible. Auburn University students qualify for 15 minutes whereas 23 minutes of service $30 per session fee for individual therapy for themselves. Eligibility for the sliding scale will be charged re-verified at least annually. In the event that a client does not wish to provide documentation of annual family income, the highest income bracket will be assumed. If a financial crisis exists (for 30 minutesexample, loss of job or loss of housing) that causes a client to be unable to pay their weekly therapy fee, the clinician can discuss the need for a temporary fee reduction with their licensed clinical supervisor and the Clinic Director. With written and/or verbal documentation of financial crisis, the client’s therapy fee may be reduced by up to $15 per session for up to 10 sessions. Telephone calls to clinicians are not an effective substitute for regular therapy sessions and should be limited to emergencies. Telephone calls longer than 5 minutes will be billed at the regular session fee in 15-minute increments. In the event that consultation services are required (for example, with school professionals, psychiatrists, primary care physicians, or previous treatment providers), the client will be billed at the regular session fee in 15-minute increments. Other professional services include telephone conversations such as reviewing previous treatment records or email responses lasting longer than 15 minutesconducting school observations will also be billed at the regular session fee (in 15-minute increments). If treatment records are requested, a fee of $20 will be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the time spent performing any other service you may request of merequested documents. If you become involved in legal proceedings that require my your graduate clinician or your graduate clinician’s supervisor’s participation, you will be expected to pay for any all of your graduate clinician’s and your graduate clinician’s supervisor’s professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from your graduate clinician or your graduate clinician’s supervisor is called to testify by another party, . Full psychological evaluations have a preset charge of $700. Half of this fee is due at the same initial assessment session, and the other half is due at the feedback session. The assessment fee includes all interviews, all assessment measures, all consultations, one written report, and one feedback session. This fee also includes AUPSC mailing or faxing the written report to one professional of the client’s choice. If additional reports are requested, a fee of $250 per 4520 will be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the requested documents. In the event that a full psychological evaluation is not required, a reduced fee can be determined by the Clinic Director on a case-minutes rateby-case basis. I Assessment measures that are administered as part of therapy without a formal report will be of no additional charge to the normal therapy fee. Assessment costs do not charge for time spent writing reports exceed $700 and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed determined by the extent of testing requested by the client. Therapy clients will be charged up to their regular session fee for missed appointments and agreed upon ahead of time with a new Treatment Contractfor appointments canceled or rescheduled less than 24 hours in advance. Assessment clients will be charged $60 for missed appointments and for appointments canceled or rescheduled less than 24 hours in advance. After 3 missed appointments in one semester, clients will be considered inactive and will need to contact the Clinic Director to reinitiate services. If it has been a client misses 4 consecutive weeks of services with the clinic is open, the client will be considered inactive, and the file will be closed. If clients are more than one year since our last appointment15 minutes late for a session, then you the clinician and supervisor reserve the right to reschedule the appointment and charge up to the session fee. Clients with outstanding balances will receive a financial summary statement at the end of each month, which will detail all transactions that are made. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, AUPSC retains the option of using legal means to secure the payment. After two consecutive sessions of nonpayment, clients will need approval by the clinic director to re-initiate services at my current standard fee services. This may involve hiring a collection agency or going through small claims court which may be higher than the fee you were previously payingwill require AUPSC to disclose otherwise confidential information. In additionmost collection situations, if it has been more than one year since our last appointmentthe only information AUPSC releases regarding a client’s treatment is the client’s name, you the nature of services provided, and the amount due. If such legal action is necessary, its costs will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterincluded in the claim. INSURANCE REIMBURSEMENT You Because AUPSC is a training clinic and graduate students who are responsible not licensed clinical psychologists provide the services, third party health insurance will NOT pay for paying your full session feethe services rendered at AUPSC. I am not in-network with any The only exceptions to this situation are the cases where the Alabama Department of Human Resources or local school systems pays for services rendered at AUPSC. Thus, AUPSC will NOT file insurance companiesforms. If you decide wish to submit claims to your insurance company for pursue reimbursement for any out-of-network benefits the services you might havehave received at AUPSC, we will provide you may do sowith a bill that lists the services provided. However, be aware that the services provided will still be charged to you, you (not your insurance company, and you ) are responsible for full payment at the full paymenttime services are rendered, unless alternate arrangements have been made in advance. I have no role in deciding It is very important that you find out exactly what mental health services your insurance policy covers. You are responsible for checking If you have insurance that covers mental health services, AUPSC will be happy to refer you to a licensed therapist who might be covered by your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible company or able to file for the full session fee in these instancesreimbursement. If your insurance company doesn’t reimburse youservices are being paid for by the Alabama Department of Human Resources or a school system, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session your contract with the following Alabama Department of Human Resources or your school system requires that AUPSC provide it with information relevant to the services that are provided to you. AUPSC is also required to provide information regarding clinical diagnosis, when a diagnosis is assigned. Sometimes AUPSC is required to provide additional clinical information, such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, AUPSC will ask that you sign an Authorization Form to Release/Obtain Information in order to release information about you that is necessary for the purpose requested. This information will need become part of the Alabama Department of Human Resources or the school systems records and might be stored in a computer. Though the Alabama Department of Human Resources and schools claim to submit keep such information confidential, AUPSC has no control over what they do with it once it is in their hands. If you refuse to your insurance company allow AUPSC to release information relevant to the services that are provided to you by AUPSC, then the Alabama Department of Human Resources or the school system will not pay for reimbursement for any out-of-network benefits services provided to you might have:by AUPSC.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It The psychotherapy experience varies depending on the personalities of psychologist, the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problemsone is experiencing. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session one or two sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please MEETINGS Therapy usually entails one 45 to 50­minute session per week although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that the psychological services I insurance companies do not provide are not reimbursement for emergency situationscancelled sessions. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My hourly fee is $395 for an initial evaluation lasting 90 minutes160.00 In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate amount for other professional services you may need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, preparation of records, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party, at the same $250 per 45-minutes rate. CONTACTING ME I am often not immediately available by telephone because I do not charge for time spent writing reports and progress notes as per answer the standard routine of phone when I am with a patient. When I am unavailable, my care of youtelephone is answered by a confidential voice mail service that I monitor frequently. I also do not charge am the only person that will listen to your message. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for any time me to return your call, contact your family physician or the nearest emergency room and ask for the mental health professional on call. If I may spend collaborating with your other providers. From time to will be unavailable for an extended time, I will provide you with the name of a colleague to contact with emergencies. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I do not reveal names or other identifying information. The other professionals are also legally bound to keep the information confidential. I will note all consultations in your Clinical Record. • I practice with other mental health professionals and I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as billing. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may institute be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted to disclose information without either your consent or Authorization. In all the cases below, I will discuss the disclosure with you prior to release and make every effort to obtain your consent. PLEASE NOTE THAT IN THE PAST 17 YEARS OF PRACTICE, I HAVE NEVER YET RELEASED INFORMATION WITHOUT A PATIENT’S CONSENT. • Psychologist­patient privilege covers most cases of court ordered requests for information. However, there have been rare exceptions. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities (e.g. disability assessment), I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are rare in my practice and I have NEVER YET been required to violate a patient’s confidentiality. ▪ If I have reason to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon them, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I determine that a patient presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and others or makes reference to another person and I believe that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. I am sometimes willing to conduct this review meeting without charge. In most situations, I am allowed to charge a copying fee increases of $3.00 per page. If I refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others) which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be discussed and 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. Payment schedules for other professional services will be agreed upon ahead of time with a new Treatment Contractto when they are requested. If it your account has not been paid for more than one year since our last appointment60 days and arrangements for payment have not been agreed upon, then you 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 which will re-initiate services at my current standard fee which may be higher than the fee you were previously payingrequire me to disclose otherwise confidential information. In additionmost collection situations, if it has been more than one year since our last appointmentthe only information I release regarding a patient’s treatment is his/her name, you the nature of services provided, and the amount due. If such legal action is necessary, its costs will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafterincluded in the claim. INSURANCE REIMBURSEMENT You are responsible In order for paying us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your full session fee. I am not in-network with any insurance companiestreatment. If you decide have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to submit claims to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the full paymentsection in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. 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. Insurance benefits can be very 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 mental health services and may restrict the number of sessions they will pay for. Many patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files.. Though all insurance companies claim to keep such information confidential, I have no role control over what they do with it once it is in deciding what your insurance coverstheir hands. You are responsible for checking your insurance coverageIn some cases, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for they may share the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseinformation with a national medical information databank. I will provide you with a superbill after each session copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the following information benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Name Signature Date Rev. 06/06 NEW CLIENT INFORMATION Name Date Social Security Number Phone Numbers: (cell) (home) (business) Address (street) (city) (state) (zip code) Date of Birth Height Weight Place of Employment Occupation Referred by Do you give permission for Xx. Xxxxxx to contact the person who referred you? High Schools Attended: (Name) ( City) (State) Colleges Attended: (Name) (City) (State) Marital Status (check one): single married/living together widowed divorced/separated How long married/living together? Have you been married before? Partner's business or position Partner's age Number of children Ages and genders Local physician Date and nature of previous significant physical problems Any current physical problems, symptoms, or concerns Current prescription medications (name & dosage) Prescribed by: (Physician name & number) Currently in counseling or psychotherapy? Yes No Previous counseling or psychotherapy? Yes No If yes, Name of therapist For how long? When? Medication prescribed Previous psychiatric hospitalization Yes No If yes, where? When? Length of stay Have any family members been hospitalized for psychiatric purposes? Yes No If yes, who? When? How long? Parental Status: Living together Separated/Divorced Father Deceased Mother Deceased If living, Father's Age If Not, Year of Death Mother's Age Year of Death Highest educational level attained by: Father Mother Father's last business or position Mother's last business or position Are/were either of your parents alcoholic or drug addicted? Yes No Age and Sex of brothers and sisters: Are/were any of your siblings alcoholic or drug addicted? Yes No Are/were any of your grandparents alcoholic or drug addicted? Yes No Person to contact in case of medical or psychological emergency: Name Relationship Address Home Phone Work Phone Note: This person would only be contacted upon your consent, or upon life threatening circumstances. Name of insurance carrier Claim Address Phone number of insurer Name of insured Policy # (usually Social Security #) Group # Briefly describe what you hope will need happen or be different as a result of your psychotherapy: Is there anything else you feel it might be important for your therapist to submit to your insurance company know? If so, please explain: Please complete the following checklist. Check only those items which are TRUE or mostly true for reimbursement for any out-of-network benefits you might have:you.

PSYCHOLOGICAL SERVICES. Psychological Services include child, family, and adult psychotherapies. In addition, Psychological Services can also include Psychological Testing/Assessment and Consultation with other businesses and professionals. Psychotherapy is not easily described in general statementsa unique and sometimes complex process. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address, and I am willing to discuss them with you as our work transpires. Always ask me questions about your treatment whenever you have them. Psychotherapy is not like different than a medical doctor visit. InsteadInstead of being told what to do to solve your problem, it calls for a very e.g., take prescription medications or undergo surgery, Psychotherapy involves more active effort participation on your part. In order for the therapy Psychotherapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can also have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleepgiven that it is impossible to predict all the issues involved in anyone’s problems at the outset, and less fatigue. But there are no can never be specific guarantees as to of what you will experienceexperience or the achievements you might accomplish. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the psychologist or therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persistWHAT IS A CLINICAL PSYCHOLOGIST? Clinical psychologists provide two basic services: (1) Helping people resolve personal, I will be happy family and work problems using various forms of psychological treatments and (2) providing psychological testing to help you set up understand people and their problems. In the state of Pennsylvania, since 1995, Licensed Psychologists have earned a meeting with another mental health professional for a second opinionDoctoral degree which included one year of predoctoral internship. Please note that the Doctoral level psychologists also have at least one year of residency where their work is closely supervised by other licensed psychologists. Psychologists are trained in many therapeutic approaches, psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutestesting, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting scientific research. OFFICE HOURS All visits are by appointment only based on availability MEETINGS I normally conduct an intake evaluation which will last from 45 to 60 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the evaluation period itself can last over several sessions. During this time, we can both decide if I am the best person to provide the services provided will still you need in order to meet your treatment goals. Psychotherapy sessions are typically 45 to 55 minutes and are usually scheduled weekly at a time we agree on, although some sessions may be charged to youlonger, not your insurance companyshorter, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:more frequent.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and and, if so, I will give you referrals to other practitioners who whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems you hope to address. Psychotherapy is not like a typical visit to your medical doctor visitdoctor. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homewhile you are away. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve an evaluation of your needs. This phase typically lasts from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a more specific recommendations regarding your treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about sense of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment significant investment of time, money, and energy, so you should be very careful mindful about the therapist you select. If we agree to begin psychotherapy, we will also discuss the frequency of our meetings. In most circumstances, it is optimal to meet for one appointment hour (of 50 minutes duration) per week. Sometimes longer or more frequent sessions are appropriate. In some circumstances we may also agree to meet less frequently. If the frequency of our meetings is limited by my availability, your own scheduling constraints, or your financial resources, we will discuss together how this impacts your treatment and ability to reach your goals. It is important that we seek to establish an open working relationship in which we can discuss your needs, hopes, and expectations as we develop goals for your therapy. While psychotherapy can be an effective mode of treatment for a variety of problems, positive results cannot be guaranteed. I invite you have questions to let me know about any concerns that may arise about my procedures, procedures or the effectiveness of your treatment so that we should discuss them whenever can address any problems together when they arise. If your doubts persist, I will be happy glad to help you set up a meeting with another mental health professional for a second opinion. Please note You have the right to withdraw from treatment at any time, I simply ask that the psychological you inform me of your decision so that we can explore your options (including referrals to other mental health professionals) and bring some closure to our work. If, at any point during your assessment or treatment, I believe that my services I provide are not appropriate for emergency situationsyou, I will discuss this with you Psychologist Patient Service Agreement 2 and assist you in exploring your options. For emergenciesSCHEDULING APPOINTMENTS. Call (000) 000-0000 to speak with me. If I am not available, call 911 or go leave a message on my voice mail that you would like to the nearest emergency roomschedule an appointment and I will return your call. FEES My FEES. The fee for my services is $395 165 per hour (or 50 minute psychotherapy session). Exceptions to that rate may be made for an initial evaluation students or for extenuating circumstances. Reduced rates are subject to review every three months. Any phone calls lasting 90 minutesmore than 10 minutes will be billed at a pro-rated amount. Other billable services include but are not limited to: report writing, consulting with other professionals with your permission, preparation of records or treatment summaries, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party, at . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine difficulty of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I may institute fee increases charge $330 per hour for preparation and these attendance at any legal proceeding. CANCELLATIONS. There are no charges for sessions that are cancelled 24 hours in advance. Charges are negotiable in case of sudden illness, family emergencies, or accidents. All other missed appointments are billed at your regular fee. Insurance companies or EAP providers will not reimburse for missed appointments. Therefore, please be mindful that any fees you incur due to late cancellations or missed appointments will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:responsibility.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychotherapy varies depending on the personalities of the psychologist and patient, and the client as well as the particular problems the client is experiencing. I might use a variety of methods to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visitintervention. Instead, it psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about during both during our sessions and at homebetween our sessions. Psychotherapy can have benefits include both risks and risksbenefits. Because therapy often involves discussing discussion unpleasant aspects of your life, you may might experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better improved relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to Yet participation in psychotherapy cannot guarantee what you will experienceexperience or the end results. Our first session will few sessions involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what the general process of our work will include and a treatment plan to follow, if so that you decide can make an informed decision about whether to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, moneyenergy, and energymoney, so you should be very careful about the therapist you select. If you have questions about my procedures, we should can discuss them these questions whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with assist your finding another mental health professional practitioner. MEETINGS I usually conduct an evaluation that lasts from 2-4 sessions. During this time, we can both decide whether I am the best person to provide the services you need in order to meet your treatment goals. Once psychotherapy is begun, I usually schedule one 50- to 6-minute session per week at a time we agree upon; sometimes sessions are more frequent or are longer than 50-60 minutes. Once an appointment time is scheduled, you are expected to pay for a second opinionit unless you provide advance notice 24 hours prior to your appointment time. Please note If we both agree that you were unable to attend due to circumstances beyond your control, I will not charge for the psychological services session. Insurance companies do not provide reimbursement for canceled sessions. Because of my limited practice, I provide are will probably not for emergency situationsbe able to offer you an alternative appointment in the same week. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My hourly fee is $395 $ for an initial evaluation lasting 90 minutesindividuals, $ for couples and families, and $250 $ _ for each subsequent psychotherapy session (either in-person or over clinical supervision/consultation. When I increase these fees, I will offer a month’s notice during which we can discuss the telephone) lasting 45 minutesimpact of this increase. In addition to weekly appointments, I charge this same $250 per 45-minutes rate fee for other professional services you may might need, though although I will prorate the cost if I work fee for periods of less than 45 minutes one hour; I charge a minimum fee of 50% your usual fee for any time in increments excess of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include report writing, telephone conversations or email responses lasting longer than 15 minutesconversations, consulting with other professionals (with your permission), and the time spent performing any other service you may request of me. If you become involved in with legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. CONTACTING ME Due to my work schedule (I am in my Olympia practice one day per week; I am in my Seattle practice two days per week), at the same $250 per 45-minutes rateI am often not immediately available by telephone. I am in my Olympia office on Mondays and my Seattle practice on Thursdays, Fridays, and/or Saturdays. I do not charge for answer my phone when I am in appointments with clients. You can leave me a message on my cell phone answering service any time spent writing reports and progress notes as per during the standard routine of my care of youday or night. I also do not charge for any time I may spend collaborating with make every effort to return your other providerscall within 24 hours. From time Please leave your area code and phone number as well as possible times that you are available to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at take my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesreturn call. If you decide are unable to submit claims reach me or cannot wait for me to return your insurance company for reimbursement for any out-of-network benefits you might havecall, you may do so. However, be aware that please contact one of the services provided will still be charged to you, not following resources: your insurance company, and you are responsible family physician; 911; the nearest emergency room for the full paymentpsychologist/psychiatrist on call; the Crisis Clinic at (000) 000-0000 or (000) 000-0000. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, When I am not responsible away from the office for refunding you any payment you expected to be reimbursed or otherwise. an extended period of time, I will provide you with a superbill after each session with the following information that you will need name and contact number of a colleague to submit to your insurance company for reimbursement for any out-of-network benefits you might have:contact in case of emergency.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional psychologist for a second opinion. Please note that the I do not conduct evaluations for disability, Family and Medical Leave Act (FMLA), or Emotional Support Animals (ESA). Please inform me immediately if you are here seeking psychological services for the purpose of filing for disability, FMLA, or ESA, so that you can be referred elsewhere. (Please initial here after reading this page ) MEETINGS I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide are not for emergency situationsthe services you need in order to meet your treatment goals. For emergenciesIf psychotherapy is begun, call 911 or go to the nearest emergency roomI will usually schedule one session per week at a time that we agree on. FEES My fee is $395 for an initial evaluation lasting 90 minutes60-minute, 45-minute, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes30- minute sessions are available. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment is scheduled, you will be expected to pay for any professional time it unless you provide 24-hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control.) CONTACTING ME Due to my work schedule, I spend on your legal matteram often not immediately available by telephone. While I am usually in my office between 12 p.m. to 6:00 p.m., even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail. I return phone calls Monday through Friday from noon to 1 p.m. with the exceptions of holidays and scheduled vacation days. If you are unable to reach me and feel that you can’t wait for time spent writing reports me to return your call, contact your psychiatrist, family physician, nearest emergency room, or Crisis Services of North Alabama at 000 000-0000. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communication between a patient and progress notes a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as per follows: • I may occasionally find it helpful to consult other health and mental health professions about a case. During consultation, I make every effort to avoid revealing the standard routine identity of my care of youpatient. The other professionals are legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I also do not charge for any time I may spend collaborating with will note all consultations in your other providersClinical Record (PHI). From time • Disclosures required to timecollect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may institute fee increases be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and these will be discussed a request is made for information concerning your diagnosis and agreed upon ahead of time with a new Treatment Contracttreatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or by court order. If it you are involved or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, I may disclose information relevant to that claim to the patient’s employer or the insurer. (Please initial here after reading this page ) There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I know or suspect that a child under the age of 18 has been more than one year since our last appointmentabused or neglected, then you will re-initiate services at my current standard fee which the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be higher than required to provide additional information. • If I know that an elderly or disabled adult has been physically, emotionally or sexually abused, neglected, or exploited, the fee law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be required to provide additional information. • If I believe that disclosing information about you were previously payingis necessary to prevent or lessen a serious and imminent threat to the health and safety of an identifiable person(s), I may disclose that information, but only to those reasonably able to prevent or lessen the threat. If one of these situations arises, I will make every effort to fully discuss it with you before taking any action and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should be helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In additionsituations where specific advice is required, if it has been more than one year since our last appointmentformal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If I refuse your request for access to your records, you have a right of review, which I will be scheduled for another initial evaluation (90 minutes) discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and charged accordinglydisclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected health information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session feethe attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. (Please initial here after reading this page ) Please note that only ADA-compliant service dogs are allowed in this office. The Americans with Disabilities Act (ADA) does not in-network with mandate any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations action regarding emotional support animals (i.e., cancellations within 24 hours of serviceESA), and telephone session emotional support animals are not typically covered allowed in this office. Two federal laws, the Fair Housing Act and the Air Carrier Access Act, require reasonable accommodations for ESA in housing and air travel only. Professional offices are not required by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected law to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:allow emotional support animals.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described may involve a variety of activities designed to support you in general statementssuccessfully resolving the difficulties or conditions, which have led you to seek therapy. It varies depending on the personalities of the psychologist is a learning process: Your therapy will be most successful if you engage openly and patienthonestly in it, and the particular problems apply what you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on discovering in how you live your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homelife. Psychotherapy can have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, These feelings (and others which you may dislike) are often an essential element in successful therapy; such therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads can lead to better relationships, solutions to specific problems, and significant reductions increases in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapyone's well being. You should evaluate consider this information along with your own opinions about in choosing whether you feel comfortable working to work with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresapproach or other relevant matter, we should discuss please bring them whenever up as they arise. If your doubts reservation or objections persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciesAPPOINTMENTS/SESSIONS If we agree to begin psychotherapy, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)usually schedule appointments as agreed upon between us. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment hour is scheduled, you will be expected to pay for any professional it unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. My fee is $110 for Individual Therapy and $130 per hour for Couples Counseling CONTACTING ME Much of the time I spend on your legal matteram not immediately available by telephone. When I am unavailable, even if the request comes from another party, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge for time spent writing reports will make every effort to return your call promptly, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please leave in your message some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session feeavailable. I am not in-network with any insurance companiesmay also be reached by email at: xxxxxxxxxxxx@xxxxx.xxx. If you decide are unable to submit claims reach me and feel that you can’t wait for me to return your insurance company for reimbursement for any out-of-network benefits you might havecall, you may do so. However, be aware that contact your family physician or the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours University of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesNeuropsychiatric Institute. If your insurance company doesn’t reimburse youI will be unavailable for an extended time, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you with a superbill after each session name of a colleague to contact if necessary. CONFIDENTIALITY Professional ethics as well as the laws of the State of Utah protect the privacy of communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Unless you specifically request otherwise, your signature on this Agreement provides consent for those activities. I am required to disclose confidential information if certain specific conditions exist. These are detailed in the accompanying Notice of Policies and Practices to Protect the Privacy of Your Health Information. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. PROFESSIONAL RECORDS AND PATIENT RIGHTS HIPAA sets forth specific definitions and standards for Protected Health Information. These are detailed in the following information that you will need accompanying Notice of Policies and Practices to submit to your insurance company for reimbursement for any out-of-network benefits you might have:Protect the Privacy of Your Health Information.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist provider and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there There are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note PSYCHOTHERAPY SESSIONS I normally conduct an evaluation that will last from 1 to 2 sessions. During this time, we can both decide if I am the psychological services I best person to provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may needneed in order to meet your treatment goals. Once psychotherapy has begun, though I will prorate the cost if I work for periods of less than usually schedule one 45 minutes in increments of 15 minutesor 60 minute session per week at a time we agree on, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will although some sessions may be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)longer or more frequent. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment hour is scheduled, you will be expected to pay for any professional time I spend on it unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol). I It is important to note that insurance companies do not charge provide reimbursement for time spent writing reports cancelled or “no show” sessions. Habitual cancellations (3 or more) will result in a referral to another agency. PROFESSIONAL FEES Fees have been revised as of 01-20-14, and progress notes as per the standard routine of my care of youare based on current insurance reimbursement schedules. I also do not charge for any time I may spend collaborating with Please contact your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your agent or insurance company to determine your mental health benefits and your obligation for reimbursement for any outco-ofpay, deductible, co-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization proceduresinsurance, etc. Missed appointmentsWe will file your claim, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that but you will need to submit to pay your expected portion on the day of your appointment. The intake/evaluation session is billed at an hourly rate of $185.00. Thereafter, my hourly fee is $140.00 for individual therapy, and $115.00 for family therapy. The fee for a 45 minute session is $95.00. Your insurance company for reimbursement for any out-of-network benefits you might have:will have a set limit which they will pay; your balance will be adjusted accordingly after the claim has been processed.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist clinician and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation assessment of your needs. By the end of the evaluationassessment, I will be able to offer you some first impressions of what our work will include and a treatment plan to followinclude, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help facilitate a referral to another treatment provider. MEETINGS If psychotherapy is begun, I will usually schedule one 50-55-minute session (one appointment hour of 50-55 minutes duration) per week at a time we agree on. Once an appointment is scheduled, you set up may be expected to pay a meeting with another mental health professional $50 charge unless you provide 24 hours advance notice of cancelation. The charge will be $75 for a second opinionevening appointments (4pm or later). Please (It is important to note that the psychological services insurance companies do not provide reimbursement for missed sessions. Though I provide do offer reminder messages as a courtesy, your appointments are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. your responsibility.) PROFESSIONAL FEES My fee for the first session is $395 for an initial evaluation lasting 90 minutes145. Subsequent sessions are charged at $135 per 53-minute session. In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I may charge this same $250 per 45-minutes rate amount for other professional services you may might need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include letter or report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationparticipation (whether or not you initiated these proceeding), you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation time, even if the request comes from I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at the same $250 per 45-minutes rateany legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. My office hours are by appointment only. I do will not charge for time spent writing reports and progress notes as per answer the standard routine of my care of you. phone when I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time am with a new Treatment Contractclient. When I am unavailable (including during normal business hours), my telephone is answered by an answering machine that I monitor frequently. You can expect to hear a response from me 12-24 hours during weekdays, and by the next business day if on the weekend or holiday. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please inform me of some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesavailable. If you decide are unable to submit claims reach me and are in an emergency situation you should call Crisis Response Services at 0-000-000-0000, available 24 hours a day. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a clinician. In most situations, I can only release information about your treatment to your insurance company for reimbursement for any out-of-network benefits others if you might havesign a written Authorization (release) form that meets certain legal requirements imposed by HIPAA and/or Maine law, or in some cases, if you may do soprovide oral authorization. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full paymentin some situations no authorization is required. I have no role may use or disclose PHI without your consent or authorization in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need circumstances: • Child Abuse • Adult and Domestic Abuse • Health Oversight Activities • Judicial and Administrative Proceedings • Serious Threat to submit to your insurance company Health or Safety • Worker’s Compensation (See HIPAA Notice for reimbursement for any out-of-network benefits you might have:further explanation and details.)

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to about what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At Should we decide that psychotherapy or counseling is the end of best course, we will decide together on the evaluationbest route. Most usual recommendations are for individual, I will notify you if I believe that I am not couple, or family sessions (generally 45 minutes long), or group sessions (generally an hour and a half). In most cases, the right therapist for you and if sorecommendation is to begin on a weekly basis, I will give you referrals to other practitioners who I believe are better suited to help youalthough this can vary depending upon circumstances. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My customary fee is $395 130 for an initial evaluation lasting 90 minutesindividual, couple, and family sessions, and $250 65 per meeting for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutesgroup sessions. I In addition to regularly scheduled appointments, it is my practice to charge this same $250 125 per 45-minutes rate hour, on a prorated basis, for other professional services you may needrequire such as psychological testing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutesreport writing, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations which last 10 minutes or email responses lasting longer than 15 minuteslonger, and attendance at meetings or consultations with schools or other professionals which you have authorized, preparation of records or treatment summaries, or the time spent performing required to perform any other service which you may request of me. Authorized professional meetings that require travel, such as school consultations, will include the same pro rated charge for travel time. None of these meetings will ever be arranged or conducted without prior discussion and consent. If you become involved in legal proceedings litigation that require requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from I am compelled to testify by another party. Because of the complexity and difficulty of legal involvement, I charge $200 per hour for preparation for, and attendance at, any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the same $250 per 45time it is held, unless we agree otherwise. Participation in groups may require pre-minutes ratepayment for a series of group meetings, and divorce assistance, such divorce mediation and collaborative divorce coaching, may require a retainer. Bills are provided at the end of each month. Each billing statement contains the information required for insurance purposes, including a diagnostic code. I do not charge ask that you take personal responsibility for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with submitting your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims bills to your insurance company each month. This helps me to keep my clerical services to a minimum which, in turn, helps me to keep my charges to a minimum. With the exceptions of emergencies or illnesses, failed appointments and cancellations without 24 hours notice are charged at the customary rate and coded on your billing statement as a "missed appointment" or “cancelled with insufficient notice.” You are fully responsible for reimbursement payment of these charges; insurance will usually not cover them. If payment lapses by more than two months and suitable arrangements for any out-of-network benefits payment have not been agreed to, I will have to affix a $10 per month fee each month thereafter to cover paper work. Payments that lapse two months or more may result in termination of service, and initiation of collection procedures. If legal action becomes neces- sary, the costs of bringing that proceeding will be added to the claim. In these circumstances, all I release are patient’s name, contact information, dates of service, and amount due. Understandable problems with payment; for example, extended periods of unemployment, will be dealt with on an individual basis. Money is a sensitive matter and is always open to discussion. Open communication is our best way to avoid problems. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important that you might haveevaluate what resources are available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions, you may do soshould call your plan administrator. HoweverOf course, I will provide you with whatever information I can based on my experience and will be aware happy to try to assist you in deciphering the information you receive from your carrier. It is important to note that the services provided will still be charged to ultimately you, and not your insurance company, and you are is responsible for payment of fees. They are there to help if your plan allows for it. If you have a managed care plan, you need to find out if I am a member of that plan. If I am, then the full paymentplan will set my fee schedule and your co-payment obligation. If I am not, then you need to find out how you go “out of network" to use my services. Many plans will allow you to do this, although you may have to meet a different deductible and co-payment obligation. Do not let your insurance administrator dissuade you from using the provider of your choice; in most cases, there is a way to do this. Managed health care plans such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards short-term treatment. Therefore, it is not unusual for me to have to seek approval for additional sessions following the initial authorization. Usually such requests are granted; but there is no guarantee. Should your benefits end before you feel finished, we can discuss a variety of treatment options elsewhere. You should also be aware that most insurance agreements require that I provide a clinical diagnosis, and sometimes additional clinical information such as a treatment plan or summary, or in rare cases, a copy of the entire record. This information will become part of the insurance company files, and, in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no role control over what they do with it. In some cases they may share the information with a national medical information data bank. Therefore, it is important to remember that you always have the right to pay for my services yourself and avoid the complexities and potential violations of privacy that are described above. Please feel free to talk to me about non-insurance options. CONTACTING ME I am often not immediately available by telephone. While I am usually in deciding what my office during daytime hours, Monday through Friday, I will not answer the phone when I am with a patient. However, I do check my voice mail on a regular basis, and will generally be able to return your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations call within 24 hours of service)hours. I am less responsive on weekends and holidays, and telephone session are will generally return calls during the next business day. If you cannot typically covered by insurance companies reach me, and therefore you will likely be responsible feel that you cannot wait for me to return your call, you should call your family physician or the emergency room at the nearest hospital and ask for the full session fee in these instancesmental health professional on call. If your insurance company doesn’t reimburse you, I am not responsible unavailable for refunding you any payment you expected to be reimbursed an extended time, such as attending professional meetings or otherwise. vacations, I will provide you a superbill after each session with the following name of a trusted colleague whom you can contact, if necessary. If I receive or return your call on my cell phone, I will inform you of this and offer you the option of waiting for me to call you back when I reach a land-based phone. The latter assures privacy. LIMITS ON CONFIDENTIALITY The law protects the privacy of communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities. Most notable of these situations are my consulting with other health and mental health professionals about your case. During such consultation, I make every effort to avoid revealing your identity. The other professionals are also legally bound to keep all information confidential. I will tell you about these consultations only when I feel it is important to our work together. All consultations will be noted in your Clinical Record. You have the right to access these. Also, since I often practice with other mental health professionals and may employ administrative staff, I may need to submit share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of these individuals are bound by the same rules of confidentiality. All staff members will have been given training about protecting your privacy and will have agreed not to release any information outside of the practice without the permission of a professional staff member. As detailed in the New Hampshire Notice Form, there are some situations where I am permitted or required to disclose information without either your insurance company consent or Authorization. Most notable of these are responding to court orders and to governmental agencies requesting information for reimbursement for health oversight activities (e.g., licensing and ethics committees), workers compensation claims, lawsuits filed against me where I am allowed to defend myself, suspected cases of child, elder, disabled or domestic abuse, and situations where there is clear and substantial risk of imminent serious harm to one’s self or to others. In these latter instances, I am morally and legally obligated to take protective actions such as initiating hospitalization and/or contacting the potential victim, and/or the police, and/or the patient’s family. If any out-of-network benefits of these situations arises, I will make every effort to fully discuss it with you might have:before taking any action and I will limit my disclosure to what is necessary.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsdescribed. It varies depending on the personalities of the psychologist therapist and patientclient, and the particular problems you hope to addressthe client is experiencing. There are many different methods I may use to deal with those help address different problems. Psychotherapy is not like a typical medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during in and outside of our sessions and at homesessions. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and or helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better improved relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Meetings Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to followmay include. However, if during the initial assessment period I determine, in my professional judgment, that I am not a good fit for your particular treatment needs, I will provide possible referral sources for you decide to continue with me for therapycontact. You In addition, you should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youme is a good fit. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresany questions, we should discuss please feel free to ask them whenever as they arise. If your doubts persistpsychotherapy is begun, I will usually schedule one 55-minute session (one appointment hour of 55 minutes duration) per week at a time we agree on, although this may vary. It is extremely important that you attend your appointments regularly. Multiple missed appointments decrease your chances of getting better and inhibits our ability to care for you. We require one business days notice if you decide to cancel or reschedule your appointment (24 hours). This will allow us to schedule another client into that time who may need to be happy seen quickly, since our schedules are often booked several weeks in advance. We consider a late-canceled appointment (i.e., an appointment canceled with less than one business days notice) to help you set up be the same as a meeting missed appointment. Late-cancellations or missed appointments are, in our experience, most often due to a client not considering their treatment a priority or being dissatisfied in some way with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situationstheir treatment provider. For emergencies, call 911 missed appointments or go to late cancellations a fee may be assessed: for the nearest emergency roomfirst event a 50% charge of the scheduled fee. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person Additional late cancellations or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service missed appointments will be charged for 15 minutes whereas 23 minutes at 100% of service the provider’s fee. With this in mind, it is our policy that if you miss or have two (2) late- cancellations or missed appointments within a twelve (12) month period, we will be charged for 30 minutes). Other professional services include telephone conversations refer you to another clinic or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which provider who may be higher than the fee you were previously payinga better match. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45rev. 11-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in3-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:14

PSYCHOLOGICAL SERVICES. Psychotherapy Family therapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part, and on my part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Also, family therapy may devote sessions to the whole family, part of the family (such as a parent and child), or members of the extended family or caretakers. All of this will be discussed in advance of any such sessions. CLIENT NAME(S): Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It The experience of psychotherapy varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. I utilize a variety of therapies and integrate them to provide a customized therapeutic experience. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very an active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Although I typically see consistent success in my work with patients, improved sleep, and less fatigue. But there are no I cannot provide guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my practice or procedures, we should I would like for you to discuss them with me whenever they arise. If at any point, the nature of the therapy becomes such that I am no longer in a comfortable position to be the therapeutic provider, we will discuss the situation and I may make recommendations and/or a referral to another competent therapist. MEETINGS / CANCELLATIONS I normally conduct an evaluation that will last approximately 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your doubts persisttreatment goals. If psychotherapy is begun, I will usually schedule one 45-50 minute session per week at a time we agree on. Once an appointment time is scheduled, you will be happy expected to help pay for it unless you set up a meeting with another mental health professional for a second opinionprovide 48 hours advance notice of cancellation [unless we both agree that you were unable to attend due to urgent circumstances]. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My fee is $395 200 for an initial evaluation lasting 90 45 minutes, and $250 for each subsequent psychotherapy session (either in-person or over due at the telephone) lasting 45 minutestime of service. I charge this same $250 per 45-minutes rate amount for other all my professional services you may needservices, though I will often prorate the this cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include letter and report-writing, telephone conversations or email responses lasting longer than 15 5 minutes, and attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any my professional time I spend on your legal matter, even if the request comes from I am called to testify by another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patient, and the patient as well as the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like feelings, such as, sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go have gone through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions reduction in feelings of distress. However, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health care professional for a second opinion. Please note THERAPY SESSIONS I normally conduct an evaluation that will last from 1-2 sessions. During this time, we can both decide if I am the psychological best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 50-minute session (one appointment hour of 50 minutes duration), once per week, at a time we both agree upon; however, some sessions may be longer or more frequent. Once an appointment is scheduled, you will be expected to pay for the session unless you provide are not for emergency situations48 hours advanced notice of cancellation, otherwise, a $125.00 no-show/late cancellation fee will apply. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My hourly fee is $395 for an initial evaluation lasting 90 minutes175.00. In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate amount for other professional services you may need, though although I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 5 minutes, attendance at meetings with other professionals you have authorized me to see on your behalf, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any my professional time I spend on your legal mattertime, even if the request comes from I am called to testify by another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities encompasses a variety of the psychologist services and patient, and the particular problems you hope to addresstechniques. There are many different methods I your therapist may use to deal help you with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort Successful outcomes rely on your part. In order for being active in the therapy to be most successfulprocess, and you will might have to work on things we talk about both during our at home between sessions. The therapist’s job is not to “fix” your problem; rather, to be a guide and teacher to help you navigate a new way of thinking about and dealing with troubling issues. Techniques and strategies learned in therapy sessions and at homeonly begin to work when they are used in your daily life. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first impressions of what our work will include and include, along with a suggested treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selecttherapist. If you have questions about my our procedures, we they should discuss them be discussed whenever they arise. If your doubts persist, I we will be happy to help you set up a meeting with another mental health professional for a second opinionrecommend other clinicians. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy APPOINTMENTS We will usually schedule one 50-minute session (either in-person one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or over the telephone) lasting 45 minutesmore or less frequent, as agreed upon between you and your therapist. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment is scheduled, you will be expected to pay for any professional time I spend on it unless you provide 24 hours advance notice of cancellation (unless you and your legal mattertherapist both agree that you were unable to attend due to circumstances beyond your control). Notice of cancellation may be given by phone, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractemail or text message. If it has been more than one year since our last is possible, we will try to find another time to reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities particular problem you bring to treatment, the consistency of the psychologist and patientattendance, and the particular problems you hope to addressamount of effort put forth in your work with your therapist. There are many different methods I that may use be used to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your partthe problem you hope to address. In order for the therapy to be most successful, you will have to work on things we talk about you discuss with your therapist both during our sessions and at homeoutside of sessions. Psychotherapy can have many benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessnessloss. When treating insomnia specifically, therapy might cause you Make sure to experience increased sleepiness discuss these feelings with your therapist in order to effectively manage your ability to cope with these negative feelings and fatigue, especially in the early phases of treatmentexperiences. On the other hand, psychotherapy has also been shown to have significant benefits for people who go through itengage in treatment. Therapy often leads to better relationships, finding solutions to specific problems, personal growth, better relationships, and significant reductions reduction in feelings of distress, improved sleep, and less fatigue. But While there are no guarantees as to what you will experience, most clients report having benefitted greatly from therapy. Our Your first session few sessions will involve an evaluation of your needs. Your therapist will normally conduct an evaluation that can last from one to three sessions. We ask clients to commit to at least three sessions before deciding if the therapist, or therapy in general, is for them. During this time, you and your therapist can decide if they are the right fit to help you achieve your treatment goals. By the end of the this evaluation, I your therapist will be able to offer you some first impressions of what our work the problem, how therapy session will include proceed and a treatment plan to you both will follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about feelings of whether you feel are comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour therapist. If you have questions about my proceduresany part of this process, we you should discuss them with your therapist whenever they arise. If your doubts persist, I we will be happy to help you set up a meeting with another mental health professional through a referral process. MEETINGS AND MISSED OR CANCELED APPOINTMENTS Therapy sessions are typically scheduled between 45 and 60-minutes per week at a time that both you and your therapist will agree on. Some sessions may be longer based on your needs and the frequency of sessions may also vary. Some clients benefit from weekly sessions while others may benefit from bi-weekly sessions. Discuss this with your therapist early in treatment so you have a clear understanding of the rational for a second opinionfrequency of sessions. Please note that Once an appointment is scheduled, you will be expected to attend the psychological services I session unless you provide are notice of cancellation by 5:00 pm the day prior to your appointment. A fee in the amount of $50.00 will be assessed for missed appointments and/or late cancelations if notice is not for emergency situations. For emergencies, call 911 or go given by 5:00 pm the day prior to the nearest emergency roomsession. Your therapist may be willing to negotiate this fee based on the cost of your individual sessions. We understand that there are instances where emergencies may arise. However, in these situations, your therapist has full digression whether to charge the fee or not. Your therapist will handle missed appointments/late cancelations on a case by case basis and there is no guarantee that your particular situation will warrant a waiving of the fees. PROFESSIONAL FEES My fee is $395 for an initial evaluation lasting 90 minutesProfessional fees vary between therapist. Session fees may also vary depending on the day, time, and $250 type of your appointments. Make sure to discuss these fees with your therapist prior to beginning treatment. In addition to charges for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I sessions, your therapist may also charge this same $250 per 45-minutes rate fees for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)they provide. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of methem. If you become involved in legal proceedings that require my your therapist’s participation, you will be expected to pay for any professional time I spend on your legal mattertheir time, even if the request comes from called to testify by another party. Because of the difficulty of legal involvement, a charge of $300 per hour for preparation and attendance at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these legal proceeding will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:assessed.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per APPOINTMENTS Appointments will ordinarily be 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 50 minutes in increments of 15 minutesduration, rounded once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the full fee for the appointment (in legal proceedings that require certain circumstances I may waive this policy, e.g. hospitalization). Please note: Even patients with Blue Cross Blue Shield will have to pay my participationnormal fee of $ 150.00 as Health Insurance companies do not reimburse for any part of a missed, or late-cancelled appointment, thus, you will be expected to pay responsible for any professional time I spend on your legal matter, even if the request comes from another party, at portion of the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes fee as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractdescribed above. If it has been more than one year since our last is possible, I will try to find another time to reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what coming to your insurance covers. You session on time; if you are responsible for checking late, your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you appointment will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will still need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:end on time.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientDuring our first few sessions, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you we will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause discuss what brought you to experience increased sleepiness and fatigue, especially in the early phases of treatmenttherapy. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you These sessions will experience. Our first session will involve an evaluation of your needstypically include informal (unstructured) assessment. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour doctor. If you have questions about my our procedures, we should discuss them whenever they arise. If A few things to remember: ∙ Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your doubts persistpart. You will likely have "homework" to complete between sessions. ∙ Sometimes undesirable behaviors increase in intensity before they lessen when you start addressing them. This is normal and usually temporary. ∙ Psychotherapy can have benefits and risks. These may vary depending on your reason for coming to therapy. While there are no guarantees of what you will experience, I will most people benefit from therapy. Benefits may include improved sleep, better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, because therapy may involve discussing challenging aspects of your life, you could at times experience difficult emotions or discomfort. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • You should be happy to help you set up a meeting with another aware that the office includes other mental health professional professionals and administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. • We have a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciescontract with Azalea Health, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minuteswhich administers our electronic health records, and $250 Gateway EDI, our insurance filing service. As required by HIPAA, we have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, the doctor may be obligated to seek hospitalization for each subsequent psychotherapy session (him/her or to contact family members or others who can help provide protection. There are some situations where your doctor is permitted or required to disclose information without either inyour consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning our professional services, such information is protected by the psychologist-person patient privilege law. We cannot provide any information without your written authorization, or over the telephone) lasting 45 minutesa court order. I charge this same $250 per 45-minutes rate for other professional services If you may needare involved in or contemplating litigation, though I will prorate the cost if I work for periods of less than 45 minutes you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If you do request your information to be shared in increments of 15 minutes, rounded to the nearest 15-minute increment a legal matter (e.g., 22 minutes Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of service $185.00/hour will be charged applied for 15 minutes whereas 23 minutes preparation of service will be charged a clinical summary, as it is our policy not to share clinical notes with anyone besides other healthcare professionals. This is for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutesyour protection, as they are written in clinical, not legal language, and the time spent performing any information contained in them could be misinterpreted. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against either doctor or the practice, we may disclose relevant information regarding that patient in order to defend ourselves. • If a patient files a worker’s compensation claim, and we are providing treatment related to the claim, we must, upon appropriate request, furnish copies of all medical reports and bills. • If a patient leaves one of the doctors or the practice a negative review online, we reserve the right to respond at that site. We will make every effort to not disclose protected health information other service you than what we did to address the problem that prompted the review. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may request have to reveal some information about a patient’s treatment. These situations are unusual in this practice. ▪ If your doctor has reason to believe that a child has been abused, the law requires that she file a report with the appropriate governmental agency, usually the Department of meHuman Resources. Once such a report is filed, we may be required to provide additional information. ▪ If your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may be required to provide additional information. ▪ If your doctor determines that a patient presents a serious danger of violence to another, she may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, your doctor will make every effort to fully discuss it with you become involved before taking any action and she will limit her disclosure to what is necessary. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in legal proceedings that require my participationyour records; and the right to a paper copy of this Agreement, you the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not charge Payment schedules for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these professional services will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You to when they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesrequested. If your insurance company doesn’t reimburse youaccount has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I am not responsible for refunding you any payment you expected we have the option of using legal means to be reimbursed secure the payment. This may involve hiring a collection agency or otherwisegoing through small claims court which will require us to disclose otherwise confidential information. I will provide you In most collection situations, the only information we release regarding a superbill after each session with patient’s treatment is his/her name, the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:nature of services provided, and the amount due. INTERNET CONTACT

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statements. It varies depending on the personalities part because of the psychologist clearly defined rights and patient, responsibilities held by each person. This frame helps to create the safety to take risks and the particular problems support to become empowered to create change. As a client in psychotherapy, you hope have certain rights and responsibilities that are important for you to addressknow about. There are many different methods I may use also legal limitations to deal with those rights that you should be aware of. We, as therapists, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first initial impressions of what our your work together may include. At that point, we will include discuss your treatment goals and create a personalized, initial treatment plan to followplan, if you decide to continue with me for therapycontinue. You should evaluate this information along with as well as your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour therapist. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions or concerns about my your therapists’ procedures, we should ask to discuss them whenever they arise. If APPOINTMENTS: We normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if your doubts persist, I will be happy therapist is the best person to help you set up a meeting with another mental health professional for a second opinion. Please note that provide the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you need in order to meet your treatment goals. If psychotherapy is begun, we will usually schedule one, 1-hour session per week at a time you both agree on, although some sessions may need, though I will prorate the cost if I work be longer or more frequent. CANCELLATION: Psychological services are most effective when meeting times are regular and consistent. The time scheduled for periods of less than 45 minutes in increments of 15 minutes, rounded your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved in legal proceedings need to cancel or reschedule a session, it is required that require my participationyou provide more than 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hours notice, you will be expected must pay the appropriate fee (usually half of the session cost) for the missed session. It is important to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I note that insurance companies do not charge provide reimbursement for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously payingcancelled sessions. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for coming to your session on time and at the full paymenttime scheduled. I have no role in deciding what If you are late, your appointment may still need to end on time. Indicate agreement to cancellation policy with your initials here: FEES, BILLING, AND PAYMENT: We use a third party (Sunrise Medical Billing) to process payments, verify benefits and bill insurance coverscompanies for services provided. You Psychotherapy sessions are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations 50 minutes to an hour and billed at $120 per hour session (i.e., cancellations within 24 hours initial sessions are $160; other fees are dependent upon service provided and will be arranged at the time of service). Session fees or insurance co-pays are payable at time of service. If you are a cash-paying client, you must fill out and telephone session sign the appropriate agreement. All payment arrangements must be I writing and signed by both the client and the therapist. Fees will be reevaluated periodically. You will be responsible for paying the entire fee if your insurance fails to cover your services. Moreover, legal fees ($250 per hour of service provided) are not typically covered by billable to insurance companies and therefore will be charged to the patient directly (e.g. court evaluations, court appearances). Should a balance accrue and no payment is received, ITTC & Sunrise Medical Billing reserves the right to seek remuneration by any means legally possible including, but not limited to, the retention of a collection agency. You may contact Sunrise Medical Billing at: 000-000-0000 | PO Box 5 | Ridgefield, WA | 98642 Indicate agreement to fees, billing, and payment policy by your initials here: INSURANCE: We accept payment directly from insurance companies, and our therapists are participating providers on several managed care preferred provider plans. In the event that we are not a participating provider in your managed care plane, our services are typically reimbursable. Insurance companies sometimes require a formal diagnosis with their claims. Diagnoses are technical terms that describe the nature of you problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-IV. There is a copy in our office and we will likely be responsible for the full session fee in these instances. If glad to let you see it to learn more about your insurance company doesn’t reimburse youdiagnosis, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:if applicable.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist psychotherapist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your therapist may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we you talk about about, both during our while you are at sessions and at homewhen you are not. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will your therapist should be able to offer you some first impressions of what our your therapy work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour therapist. Therapy involves can involve a large commitment of time, money, and energy, so you should be very use careful judgment about the therapist you select. If you have questions about my the therapy procedures, we should discuss them with your therapist whenever they arise. If your doubts persist, I we will be happy to help assist you set up a meeting to secure an appropriate consultation with another mental health professional for a second opinion. Please note that the psychological services I provide APPOINTMENTS Appointments are not often scheduled for emergency situations. For emergencies, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 1550-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend sessions on your legal matter, even if the request comes from another party, at the same $250 a once per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do soweek basis. However, be aware that ongoing therapy is a negotiated process between you and the services provided will still be charged to you, not your insurance companytherapist, and frequency of sessions is partially the decision of the client. Both you are responsible for and your therapist should periodically evaluate and discuss the full payment. I have no role in deciding what your insurance coversprogress and the process of therapy, and re-negotiate the need and frequency of further appointments. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etchave the right to terminate therapy at any time. Missed appointments, late cancellations (i.e., cancellations within 24 hours A termination session may be suggested in order to discuss progress made or areas of service)concern, and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for to allow the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you therapist to make any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:recommendations deemed necessary.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. You may also opt for a more intensive session, which would be a total of 110 minutes. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24-hour notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the psychological services I provide full amount for missing the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergenciesPROFESSIONAL FEES The standard fee for a traditional fifty-minute session, call 911 or go to the nearest emergency room. FEES My fee is $395 100. The standard fee for a two-hour, intensive appointment is $200. Currently, I do not work with any insurance companies and you are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash or credit/debit card. Any checks returned to my office are subject to an initial evaluation lasting 90 minutesadditional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, and $250 for each subsequent psychotherapy session (either in-person I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another partyparty compels me to testify. In general, at the same $250 per 45-minutes rate. I do not charge get involved in legal proceedings and my fee for time spent writing reports and progress providing notes as (only if subpoenaed) or attending court (only if subpoenaed) is $150/per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:hour.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems you hope to address. Psychotherapy is not like a typical visit to your medical doctor visitdoctor. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homewhile you are away. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve an evaluation of your needs. This phase typically lasts from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a more specific recommendations regarding your treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about sense of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment significant investment of time, money, and energy, so you should be very careful mindful about the therapist you select. If we agree to begin psychotherapy, we will also discuss the frequency of our meetings. In most circumstances, it is optimal to meet for one appointment hour (of 50 minutes duration) per week. Sometimes longer or more frequent sessions are appropriate. In some circumstances we may also agree to meet less frequently. If the frequency of our meetings is limited by my availability, your own scheduling constraints, or your financial resources, we will discuss together how this impacts your treatment and ability to reach your goals. It is important that we seek to establish an open working relationship in which we can discuss your needs, hopes, and expectations as we develop goals for your therapy. While psychotherapy can be an effective mode of treatment for a variety of problems, positive results cannot be guaranteed. I invite you have questions to let me know about any concerns that may arise about my procedures, procedures or the effectiveness of your treatment so that we should discuss them whenever can address any problems together when they arise. If your doubts persist, I will be happy glad to help you set up a meeting with another mental health professional for a second opinion. Please note You have the right to withdraw from treatment at any time, I simply ask that the psychological you inform me of your decision so that we can explore your options (including referrals to other mental health professionals) and bring some closure to our work. If, at any point during your assessment or treatment, I believe that my services I provide are not appropriate for emergency situationsyou, I will discuss this with you and assist you in exploring your options. For emergenciesSCHEDULING APPOINTMENTS. Call (000) 000-0000 to speak with me. If I am not available, call 911 or go leave a message on my voice mail that you would like to the nearest emergency roomschedule an appointment and I will return your call. FEES My You may also reach me by email at xxxxx@xxxxxxxxxxxxx.xxx FEES. The fee for my services is $395 210 per 50-minute psychotherapy session. Exceptions to that rate may be made for an initial evaluation students or for extenuating circumstances. Reduced rates are subject to review every three months. Any phone calls lasting 90 minutesmore than 10 minutes will be billed at a pro-rated amount. Other billable services include but are not limited to: report writing, consulting with other professionals with your permission, preparation of records or treatment summaries, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. Because of the difficulty of legal involvement, charges are pro-rated at $504 per hour for preparation and attendance at any legal proceeding. For more detailed information about my fees please refer to the fee schedule attached at the same $250 per 45-minutes rateend of this document. I do CANCELLATIONS. There are no charges for sessions that are cancelled 24 hours in advance. Charges are negotiable in case of sudden illness, family emergencies, or accidents. All other missed appointments are billed at your regular fee. Insurance companies or EAP providers will not charge reimburse for time spent writing reports and progress notes as per the standard routine of my care of youmissed appointments. I also do not charge for Therefore, please be mindful that any time I may spend collaborating with your other providers. From time fees you incur due to time, I may institute fee increases and these late cancellations or missed appointments will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:responsibility.

PSYCHOLOGICAL SERVICES. Psychotherapy As a Washington State Licensed Psychologist, my therapeutic work is not easily described in general statementsbased on X. X. Xxxx'x Analytical Psychology. It Xxxx believed that all psychological parts of each person are important ingredients to the process of retrieving one's true compass, developing full potential, and becoming a whole human being. Xxxx believed that each person knows her, his, or their needs, wants, and goals. In the therapeutic process, we work together to facilitate the process of re- discovering and compassionately accepting all aspects of the Self. Because psychotherapy varies depending on the personalities of the psychologist and patientthe client, and as well as the particular problems the client experiences, psychotherapy is not easily described in general statements. I might use a variety of methods to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like Unlike medical intervention, often based on physicians’ unilaterally prescribing a medical doctor visit. Insteadtreatment, it calls for a very psychotherapy involves active effort on your partby both the therapist and the client. In order for the therapy to be most successful, you will have to work on things issues we talk about both during our sessions and at homeas well as between our sessions. Psychotherapy can have benefits include both risks and risksbenefits. Because therapy often involves discussing discussion of unpleasant aspects of your life, you may might experience uncomfortable feelings like such as sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better improved relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatiguean increased sense of well-being. But there are no guarantees as to what you will experienceYet participation in psychotherapy cannot guarantee improvement in your experiences or the end results. Our first session will few sessions involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what the general process of our work will include and a treatment plan to follow, if so that you decide can make an informed decision about whether to continue with me for therapy. You should will evaluate this information along with your own opinions about perspective of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, energy, and money, and energy, so you should be very careful carefully discern your decision about the therapist you select. If you have questions about my procedures, we should will discuss them these questions whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with assist your finding another mental health professional practitioner. APPOINTMENTS/MEETINGS I usually conduct an initial evaluation that spans 2-4 sessions. During that time, we decide whether I am the person to provide the services you need in order to meet your treatment goals. After psychotherapy begins, we schedule one 50-minute session per week at a time we agree upon; occasionally, sessions are more frequent or are longer than 50 minutes. Once an appointment time is scheduled, you are responsible to pay for a second opinionthe appointment unless you provide 24-hour advance notice prior to your appointment time. Please note If we both agree that you were unable to attend due to circumstances beyond your control (e.g., last-minute illnesses/injury; transportation disruption), I will not charge for the psychological services session. Insurance companies do not provide reimbursement for canceled sessions. Based on my schedule, I provide are might not for emergency situationsbe able to offer you an alternative appointment in the same week. For emergencies, call 911 or go to the nearest emergency room. PROFESSIONAL FEES My current hourly fee is $395 150 for an initial evaluation lasting 90 minutesindividuals, $160 for couples and families, and $250 120 for each subsequent psychotherapy session (either in-person or over clinical supervision/consultation. I prorate the telephone) lasting 45 fee for periods of less than one hour; I charge a minimum fee of 50% your usual fee for any time in excess of 15 minutes. When I increase these fees, I will offer a one-month notice during which we can discuss the impact of this increase. In addition to weekly appointments, I charge this same $250 per 45-minutes rate fee for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)request. Other professional services include include, but are not limited to, report writing, telephone conversations or email responses lasting longer than 15 minutesconversations, consulting with other professionals (with your written permission), and the time spent performing any completing other service (s) you may request of merequest. If you become involved in with legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from when I am called to testify by another partyparty in your suit. CONTACTING ME The most effective means of contacting me between sessions is via phone and voice mail: (000) 000-0000. Clients can leave a message on my cell phone 24 hours per day. Due to my work schedule, at the same $250 per 45-minutes rateI might not be immediately available via telephone. I do not charge for time spent writing reports make every effort to return calls within 24 hours. When you leave a message, please leave your area code and progress notes phone number, as per the standard routine of well as possible times that you are available to take my care of youreturn call. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any My main out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. office communication modality is my cell phone (I have no role in deciding what your insurance coversland line). You are responsible I use my cell phone (rather than e-mail) for checking your insurance coverageadministration purposes, deductiblessuch as making and changing appointment times. When I receive a text message about cancellation, payment ratesI will respond that I have received the message and request that you call me to reschedule. To reschedule an appointment, preI prefer the practicality of a voice-authorization proceduresto-voice conversation. For lengthier clinical conversations, etc. Missed we will use in-person appointments, late cancellations (i.e.voice-to-voice cell phone conversations, cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible or the xxxx.xx platform. When I leave a message for the full session fee in these instances. If your insurance company doesn’t reimburse you, I will be as circumspect as possible. I will not identify myself as your therapist, and I will use my first name only. I will refer to our appointments as “meetings.” When I am not responsible away from the office for refunding you any payment you expected to be reimbursed or otherwise. an extended period of time, I will provide you with a superbill after each session with colleague’s name and contact information for contact in case of emergency. Although I have a website for my practice, the site is informational and is not interactive (i.e., not for scheduling/rescheduling appointments or sending me information): xxxxxxxxxxxx.xxx The website lists my mailing address (0000 XX Xxxxxxx Xxx, #000, Xxxxxxx, XX 00000) but not my physical office address. EMERGENCY CONTACTS If you are experiencing a crisis and are unable to reach me or cannot wait for me to return your call, please contact one of the following resources: Your family physician 911 Hospital Emergency Room: nearest hospital; nearest insurance-affiliated hospital Crisis Connects (formerly The Crisis Clinic): (000) 000-0000 (King County) LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can release information about your treatment only after you sign a written authorization form that you will need to submit to meets specific legal requirements imposed by Washington State law and/or HIPPA. With your insurance company for reimbursement for any out-of-network benefits you might havesignature on a proper authorization form, I can disclose information in the following situations:

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist Therapist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please MEETINGS I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Sessions will be scheduled at a time and frequency we agree on. Most therapy sessions will last for 45-50 minutes unless we have agreed upon a longer session. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. [If it is possible, I will try to find another time to reschedule the psychological services appointment.] PROFESSIONAL FEES You will be informed as to my current fee schedule regarding the initial diagnostic interview session, follow up 45-50 minute therapy sessions and other services. I provide are not for emergency situationsonly accept payment in the form of check or cash. For emergenciesPlease make checks payable to “Xxxxxxx Xxxxxxxx, call 911 or go to the nearest emergency roomLSCSW, Inc”. FEES My fee is $395 schedule provides a listing of rates for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records of treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. [Because of the difficulty of legal involvement, at the same I charge $250 per 45-minutes ratehour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. My telephone is answered by my confidential voice mail system. I do not charge for time spent writing reports will make every effort to return your call on the same day you make it, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please inform me of some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companiesavailable. If you decide have an emergency, call 000-000-0000 and follow the voice mail prompts. The answering service will assist you. The answering service will attempt to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do soreach me. However, be aware that the services provided will still be charged to you, not your insurance company, and If you are responsible unable to reach me and feel that you can’t wait for me to return your call, contact your physician or the nearest emergency room and ask for the full paymentpsychologist or psychiatrist on call. If you have a life-threatening emergency, call 911. If I have no role in deciding what will be unavailable for an extended time, we may discuss your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible need for the full session fee name of a colleague to contact in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:my absence.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychological counseling varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. InsteadCounseling will frequently involve discussing your personal concerns, it calls for a very active effort on your partthoughts, and feelings. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homebetween sessions. We believe that homework assignments are a necessary part of the recovery process, thus we only work with clients who are willing to engage in homework assignments. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through ittremendous benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experienceAll experiences differ. Our first session few hours together will involve an evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtogether. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we should discuss them whenever they arise. If We are happy to provide outside referrals if your doubts concerns persist. MEETINGS & CANCELLATION POLICIES We offer both 50-minute “traditional” appointments as well as an “Intensive Therapy” model (e.g., I 2-6 hours at a time; multiples days per week). The exact timing of sessions will be happy determined in consultation with you, based on your needs. A phone consultation is recommended prior to help arranging treatment. The 15-minute consultation will be done free of charge. During the consultation, we can both decide whether we are the best match to provide the services you set up a meeting with another mental health professional for a second opinionneed. Please note that the psychological services I provide are not for emergency situations. For emergenciesIf an appointment of 50 minutes, call 911 or go to the nearest emergency room. FEES My fee is $395 for an initial evaluation lasting 75 minutes, 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-110 minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationduration is scheduled, you will be expected to pay for any professional it unless you provide 48 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. If we schedule an Intensive Therapy session of greater than 110 minutes, then a deposit will be required at the time I spend on the appointment is booked. This is necessary due to the large number of hours blocked for your legal matter, even services. This deposit is only refundable if the request comes from another party, at appointment is cancelled 14 days prior to the same $250 per 45-minutes rateappointment start time. I do not Signing this agreement authorizes us to charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your credit card on file if other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. INSURANCE REIMBURSEMENT You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session arrangements are not typically covered by insurance companies and therefore you will likely be responsible made for payment for appointments cancelled or missed within the full session fee in these instancesguidelines of the cancellation policy. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:SUPERVISION INFORMATION FOR LOWER FEE OPTION