Lucid Listening

Policy Statement and Treatment Contract (Adult)

PAGE SIX  

 PRINT NAME OF CLIENT:______________________________

 WELCOME: Please feel free to ask questions regarding this information.

CONFIDENTIALITY: The information you share with me will be held in the strictest confidence, and will only be released to others with your written consent. Exceptions to this policy may be made under the following conditions, as necessary:

  • If I believe that someone’s safety is at risk, I will notify appropriate persons and/or agencies to ensure safety. Additionally, I may notify authorities if I believe that a child has been abused.

  • If a judge orders a mental health examination, or if you engage in legal proceedings that rely upon your mental or emotional condition for your claim or defense, the information in your file may be made available to the Court. If information is subpoenaed by the Court, it will be disclosed as required.

  • If you request that I bill an insurance company for services provided, clinical information is provided as required by your plan.

  • Information derived from family therapy sessions belongs to all members present for the session; any member can access this information, although all members must agree before I release information to third parties. If one member requests access to file information, I may inform other members of this action.

CLIENTS’ RIGHTS/ TREATMENT RISKS: You have the right to terminate therapy and/or evaluation services at any time. The possibility exists that you may remember unpleasant events, experience intense emotions, and/or alter personal relationships. Some problems cannot be resolved through therapy. Psychological evaluations may produce results or recommendations that are unexpected or create discomfort.

FEES: 55  Min. Initial Intake Appointment: $205 

             55  Min. Individual Therapy, with or without other family members present: $140 

             55 Min. Family Therapy, patient present: 140

Insurance co-pays and deductibles are set by your insurance company and are not regulated by this office. Please note that the following services are usually NOT covered by insurance, and are NOT always available:

  • Court Appearance (including time spent in travel, waiting, and actual testimony): $250/hour, in advance. Please note that Court Appearance charges apply if I receive a subpoena from any party - even opposing counsel - to appear in court relating to treatment you receive at this office.

  • Report writing, coordination with other providers, telephone therapy: $140/hr

  • Internet Coaching via videoconferencing: $50/ 30 minute session

If you cancel your appointment with less than 24-hour notice, or do not show for your appointment, you will be charged $35. In the event of non-payment, your account may be referred to a collection agency, and you would be responsible for all cost of collection.

I HAVE READ THESE POLICIES AND AGREE TO THEM:

Client Signature____________________________________

Date_________________

Signature of Participating Family Member(s) __________________________Date ________________

                                                                             ________________________Date _________________