Consent to Treatment and Fee
If conjoint (couple or family), all adults need to sign this contract because of confidentiality and individual rights issues even though one person is the identified patient (and paying).
In the case of an emergency, the best phone number to use is 956-345-5444. If you receive the voicemail, please leave a message. I may be on the phone, in therapy with someone else, or may be out of the office.
In a crisis situation, if I cannot be reached by you may call the 24-hour Mental Health Crisis Line: 877-289-7199, or go immediately to your local hospital emergency room.
Consent to Treatment
You have decided to embark on a powerful journey known as psychotherapy, a decision of strength and courage. Know that we consider the psychotherapeutic relationship to be one of sacred trust. This letter serves to inform you about the therapeutic process, give you some information and answer questions about the professional relationship between therapist and clients.
Psychotherapy cannot insure the successful resolution of the issues you bring to it. Human beings are far too complex and life is too uncertain. However, it is our experience as therapists that most people can gain some value from the therapeutic process. Know that as we journey together new, often unforeseen destinations may appear. The therapeutic process may not only affect you, but also relationships, work and other areas of life. There are alternatives and many adjuncts to psychotherapy. These include, but are not limited to, medications, support groups and complimentary modalities. I will be happy to discuss any alternatives you want to consider at any time.
I have a number of client expectations about the professional relationship we embark on with each client. We expect you to keep your appointments. Please remember that someone else may want this time. Please give our other clients, their obligations, relations and your therapist the courtesy of a 24 hour notice if you must cancel an appointment; otherwise, you will be charged for this time. I always consider broken appointments individually and understand that emergencies do arise. Insurance will not pay for broken appointments.
My current fee is $120 for the initial session. Individual therapy sessions are $90. I do have a sliding scale depending on your household income. Payment for your session is due at the time of service. We accept cash, personal checks, and credit cards. I work with a number of insurance companies via managed care contracts and we are responsible for filing claims for our services; you must pay your copay at the time services are rendered. There are no exceptions. Other insurance plans (out of network) are accepted but you may be required to pay the difference. Payment arrangements are discussed during your initial session.
I also charge for our time when you require written correspondence. This is billed according to the amount of time utilized with a minimum fee of $25. This would include correspondence such as letters to other practitioners, disability applications, etc. Insurance will not pay for correspondence. We do not charge for customary insurance filing. Telephone consults are also billed at regular rates. The first 5 minutes we consider a professional courtesy to our relationship; thereafter, the time is billed at regular rates to the nearest quarter hour. Sessions are 50 minutes in length. I often take a few minutes of an hour between clients to relax, let go of the last session and prepare for the next one.
My appointment times are generally on the hour from 9 AM to 5 PM. I do make earlier and later appointments but these are reserved for long standing clients. I will schedule our next appointment at the end of each session. I am in the office Monday through Saturday. You may reach me via telephone/voicemail during regular office hours. As I am in session most of the day, I do often check voice mail and return messages several times a day. If your call is non-urgent, we will respond as soon as possible. Calls left for me after 5 PM will be returned the following business day at the earliest.
If you are in a life and death emergency situation dial 911 for assistance or go immediately to your local emergency department.
Although the client-therapist sessions will be intimate psychologically, it is important for you to understand that the client-therapist relationship is professional and not social. All contact will be limited to sessions you arrange with your therapist. Sessions are usually held in one of our offices. If you should encounter your therapist outside of the office, the therapist will speak with you only if you initiate the contact; this allows you to maintain the privacy of your psychotherapeutic relationship. Please do not invite your therapist to social gatherings (including, but not limited to, parties, weddings, business meetings, etc.), offer gifts, or ask them to relate to you in any way other than the professional context of our therapy sessions. Although this may seem artificial and/or awkward, it is the best way to promote a good psychotherapeutic relationship.
Your sessions should focus on your concerns exclusively. You will learn a great deal about your therapist the longer you work together; our therapist may occasionally share experiences and struggles with some regularity as models for clients. Nonetheless, you will still be experiencing the therapist in a professional role solely. As your therapist I will keep confidential anything you say with the following exceptions: a) you direct the therapist to speak about you with someone, b) The therapist determines that you are a danger to yourself or others, or c) there is evidence of child or elder abuse. In the event of the latter two exceptions, the therapist will contact family, friends, DFCS and/or law enforcement authorities to attempt to prevent harm from coming to anyone.
As your therapist, I use an eclectic approach to therapy, meaning that they utilize a variety of therapeutic models. I work diligently to use what is most helpful for each individual rather than take any one approach exclusively. I hope this information is helpful to you. If at any time during your relationship with your therapist you have any questions, please feel free to ask.
I do hereby seek and consent to take part in the treatment provided by this provider. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.
I am aware that I (or my child) may stop treatment with this therapist at any time. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court ordered, I will have to answer to the court.)
I am aware that an agent of my insurance company or other third-party may be given information about the type (s), cost (s), and providers of any services I receive. I understand that if payment for the services I receive here is not made, the therapist may stop treatment. My signature below shows that I understand and agree with all of these statements. I have been given the opportunity to ask questions regarding this information.