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Terms and Conditions

Welcome to my practice!  This document (including the agreement) contains important information about my professional services and business policies as well as about the Health Insurance Portability and Accountability Act (HIPAA), privacy rule 45 C.R.F., a federal stipulation which provides privacy protections and clients rights with regard to the use of and disclosure of your Protected Health Information (herein referred to as PHI), used for the purpose of and disclosure of your PHI for purposes of treatment, disclosure, reimbursement and healthcare operations. The notice below, explains HIPAA and its application. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting.  When you sign this document, it will represent an agreement between us. This agreement must be signed before we begin counseling. You may revoke this agreement, in writing at any time which will be binding unless I have taken action in reliance on it or if there are any obligations or reimbursements or claims of any nature made under your policy.

 Financial Breakthrough Therapy

Is not an insurance reimbursable service. For technical reasons it is termed counseling as opposed to therapy. While it often does work with its intended purpose, no assurances can be made as to its efficacy for every individual. I accept upon myself any and all consequences resulting from this therapeutic model. I understand that I am accepting to follow through the entire program despite any unforeseen circumstances. I understand the FBT staff will be reasonable in their accommodations


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 or counseling 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.  On the other hand, psychotherapy or counseling 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, there are no guarantees as to what you will experience.

Our first 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 therapy.  Counseling is a very significant commitment which includes time, energy and money. 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 whom I believe are better suited to help you.  As stated, 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.


I normally conduct an evaluation that will last from 1 to 3 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.  If we agree to begin psychotherapy, I will usually schedule one 30 minute sesion, at a time we agree on, although some sessions may be longer or more frequent.

Signing this contract gives permission to use video and/or audio technology to conduct our session, where applicable.


In case you need to cancel your appointment, please do so with at least 24 hours advance notice. Appointments cancelled with less than 24 hours’ notice will be charged 0$200.0. Your credit card information will be requested at the first meeting and kept on file in cased of missed appointment. For Medicaid/care clients, and for private pay, one no show or 2 late cancellations will result in automatic termination of patient contract.


My 30 minute fee $200 for the session. If we meet more than the usual time, I will charge accordingly.  In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour.  Other professional services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation 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 professional time I spend on your legal matter, even if the request comes from another party.  [I charge $125 per hour for professional services I am asked or required to perform in relation to your legal matter.  I also charge a copying fee of 30 cents per page for records requests.] A fee for $50 will be charged for all checks returned due to insufficient funds.


You will be expected to pay for each session, before the 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 to when such services are requested. 

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment.  This may involve hiring a collection agency or going through small claims court.  [If such legal action is necessary, its costs will be included in the claim.]  In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due. 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.  If you have a health insurance policy, it will usually provide some coverage for mental health treatment. .PLEASE KEEP IN MIND THAT UNDER ALL CIRCUMSTANCES, you (not your insurance company) 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 section 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 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 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.  Though a lot 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 most insurance companies require that I provide them with your clinical diagnosis.  Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases).  Sometimes I am required to provide additional clinical information such as treatment plans or summaries. In such situations, I will make every effort to release only the minimal amount of information necessary. This information will become part of the insurance company files.  Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands.  In some cases, they may share the information with a national medical information databank. They may and often do share it with other individuals who they deem worthy or important enough to share it with. I will provide you with a copy of any records I submit, if you request it.  You understand that, by using your insurance, you authorize me to release such information to your insurance company.  I will try to keep that information limited to the minimum necessary.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions.  It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by the insurance contract].


I am often not immediately available by telephone.  Though I am usually in my office between [9 AM and 5 PM Mondays thru Thursdays], I probably will not answer the phone when I am with a patient.  When I am unavailable, my telephone is answered by an answering service or voice mail.  If you are difficult to reach, please inform me of some times when you will be available.  [In emergencies, you can try me at my cell number.]  If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call.  If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Please refrain from texting or emailing any information about your or someone else’s health (PHI). Please contact me directly through my business contact means to provide me with any PHI.

CONFIDENTIALITY [for adult patients]

In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission.  But there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment.  In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order. 

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment.  For example, if I believe that a child [elderly person or disabled person] is being abused, neglected or injured through physical or mental means, I must [may be required to] make a report to the appropriate state agency.

If I believe that a patient is threatening serious bodily harm to another, I am [may be] required to take protective actions.  These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.  If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.  If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action.

Pursuant to HIPAA, I keep a set of my records about you in two distinct professional records. One set is your clinical record which includes your reasons for seeking counseling, brief description of the challenges and problems, diagnosis if applicable, treatment plan and progress towards goals and any other relevant elements of your history and or treatment goals and plans. This includes payment records, billing docs, receipt’s etc. You may examine and receive it if you request it in writing and the request is dated not more than 60 days from the date you submitted the request. I charge 50 cents per copy as this must include cost of ink, printer usage etc. I also keep my own notes which are kept separately and not part of your clinical record. This is only for personal use to assist with my therapy services and I am not required to share this with any insurance companies.

Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our next meeting.  I will be happy to discuss these issues with you and provide clarification when possible.  However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney.  [If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.] Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.



Parent Authorization for Minor’s Mental Health Treatment

In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child.  If you are separated or divorced from the other parent of your child, please notify me immediately.  I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.

If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child.  I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment.  If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective.  We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress.  Ultimately, parents decide whether therapy will continue.  If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances.  However, in most cases, I will ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.

Individual Parent/Guardian Communications with Me

In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately or together.  Please be aware, however, that, at all times, my patient is your child – not the parents/guardians nor any siblings or other family members of the child.

If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records.  Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record. 

Mandatory Disclosures of Treatment Information

In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission.  I have listed some of these situations below.

Confidentiality cannot be maintained when:

  • Child patients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future.  I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.

  • Child patients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future.  In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm [and the police].

  • Child patients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person.  In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

  • Child patients tell me, or I otherwise learn that, it appears that a child is being neglected or abused--physically, sexually or emotionally--or that it appears that they have been neglected or abused in the past.  In this situation, I am [may be] required by law to report the alleged abuse to the appropriate state child-protective agency.

  • I am ordered by a court to disclose information.

Disclosure of Minor’s Treatment Information to Parents

Therapy is most effective when a trusting relationship exists between the psychologist and the patient.  Privacy is especially important in earning and keeping that trust.  As a result, it is important for children to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents.  This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.

It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement.  This includes activities and behavior that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm.  However, if your child’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm.  If I feel that your child is in such danger, I will communicate this information to you.

You can always ask me questions about the types of information I would disclose.  You can ask in the form of “hypothetical situations,” such as: “If a child told you that he or she were doing ________, would you tell the parents?”

Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life.  In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so.  Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.

Disclosure of Minor’s Treatment Records to Parents  

Although the laws of [this State] may give parents the right to see any written records I keep about your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.

Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation

When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children.  Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child.  You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.  Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled.  If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness.  If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s).  Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at the rate of $XXX per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.

Child/Adolescent Patient:

By agreeing to these terms, you show that you have read and understood the policies described above.  If you have any questions as we progress with therapy, you can ask me at any time.

Parent/Guardian of Minor Patient:

 will refrain from requesting detailed information about individual therapy sessions with my child.  I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.                                                                                                  

Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment, unless absolutely necessary.                                                                                                                                                                   

I understand that I will be informed about situations that could endanger my child.  I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.                                                                                                    

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