Consent for Treatment

Welcome! In order to better serve you, please review the following. Please acknowledge your understanding and acceptance by providing your initials in the space provided after each individual statement and your signature at the end of the document.

Psychotherapy Guidelines

Psychotherapy

I offer a range of psychotherapy services for adolescents and adults. The psychotherapy that you receive will consist of meeting with me where I will assist you in setting and working towards goals for desirable changes. There are minimal risks associated with this form of psychotherapy. Potential benefits include positive changes in individual functioning. These may result in decreases in general distress or specific symptoms.

Session Times

Psychotherapy sessions will generally occur once per week for 50 minutes or on a schedule mutually agreeable to you and me. Every effort will be made to begin and end sessions on time. If I am late beginning a session, then when possible, the session will be extended to allow for the full session time. If a patient is late for a session, then the session will usually have to end on time.

Fees

My fee is $160 per 50-minute session. If a longer appointment is scheduled, or if a standard session runs past 50 minutes, the fee will be $40 for each additional fifteen minutes. Diagnostic sessions (initial sessions) will be $200. Full payment of fees are payable at the beginning of each session. As a courtesy, insurance can be filed. I am not currently on any insurance panels but can provide the necessary paperwork to file out-of-network claims. I accept cash or check and credit cards. Checks are made payable to Durham DBT, Inc. Credit card processing is handled by Square, Inc. If for any reason an account balance has been accrued, the balance is due within 10 days of the statement/ invoice date. If for some reason payment is not received for as many as two sessions, then further services will be discontinued until all unpaid charges are paid; however, in the case of an emergency, I will make the necessary exceptions.

Cancellations/Missed Appointments

An appointment represents time reserved personally for you. Cancellation/rescheduling of appointments must be done 24 hours in advance or the fee will be charged for the session. Cancellations must be made via phone call or voice mail, not through email correspondence.
Note that insurance cannot be billed for a missed or late appointment, so you will be responsible for the entire charge of the reserved time. The reason this policy is in place is to give me an opportunity to fill the slot you have reserved/cancelled with another client who is available and in need of an appointment.

Waiver of Liability and Confidentiality

I am aware that all statements I shall make are of a confidential nature, including all written information, and ethically may not be disclosed without my written consent with the following exceptions that will result in confidentiality being waived:

1. A therapist working with an adult, adolescent, or a child is required by law to disclose to the appropriate person, agency or civil authority any harm that a person may attempt or desire to do to one’s self or to others, and is required to disclose any reasonable suspicion of physical or sexual abuse being done or having been done to a minor child or a dependent person.
2. Although the courts usually hold psychotherapy records as privileged, therapists are professionally bound to comply with subpoenas given by a court of law.

I acknowledge responsibility for all fees incurred and should collection of my account become necessary, I will be responsible for all costs of litigation including attorney’s fees. If payment for services is not received within 3 months of services rendered, then I understand that a collection agency will be notified. By providing my signature, I acknowledge that I have read, understood, and have agreed to the Psychotherapy Guidelines, the Waiver of Liability and Confidentiality, and that I accept the stated conditions and limits of confidentiality.