Lucid Listening

Policy Statement and Treatment Contract (Minor)

PAGE SEVEN

NAME OF MINOR CLIENT (print):_______________________________________ DOB:______________

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.

  • Information about clients age 17 years and younger may be shared with their parents or guardians.

  • 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

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:

  • Court testimony (including travel time): $250/hour, in advance. 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 min. 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 (2 PAGES). I AGREE TO THEM AND AUTHORIZE SERVICES FOR MY CHILD.


Sign here if you are the party accepting responsibility for payment: ___________________________    Date _________________

Sign here if you are the parent or Legal Guardian with SOLE LEGAL CUSTODY and you wish to authorize services for the child: ______________________________ Date ___________


Sign here if you are a parent or Legal Guardian with JOINT LEGAL CUSTODY and you wish to authorize services for the child: ___________________________________Date _________

                                                                ___________________________________ Date _________

Sign here if you are a non-custodial biological parent and you wish to authorize services for the child: _______________________________________ Date __________________

             _______________________________________ Date __________________

Signature of others participating in family therapy:
Relationship:______________________________________________Date _____________

Relationship:______________________________________________Date _____________