Therapy Registration Form

Client Information and Office Policy Statement

Please print, sign and date this therapy registration form:

I. Appointments:

Appointments are usually scheduled for 50 or 80 minutes. Sessions generally happen on a weekly basis with more or less frequency to be determined according to need. You may choose to end treatment at any time. In the event of an emergency. please call the Suicide Crisis Line at 831 458-5300 or go to the Dominican ER. In the event of a life threatening emergency dial 911.

II. Confidentiality

Legally, the content of your therapy sessions are considered confidential and "privileged." However, there are limits to the privilege.

These situations include:

1. Suspected abuse or neglect of a child, elderly person or disabled person.

2. When I believes you are in danger of harming yourself or -another person or you are unable to care for yourself.

3. If you report that you intend to physically injure someone the law requires your therapist to inform that person as well as legal authorities.

4. If I am is ordered by a court to release information as part of a legal involvement in litigation. (company litigation.etc).

5. When your insurance company is involved,(e.g. in filing a claim, insurance audits. case review or appeals, etc.)

6. In natural disasters whereby protected records may become exposed.

7. When otherwise required by law. You may be asked to sign a Release of Information so that I may speak with other mental health professionals or family members.

8. For purposes of collecting a debt.

III. Record Keeping:

A clinical chart containing diagnostic information, assessment and treatment planning, course of progress, fees, dates of service and session notes as well as pertinent miscellaneous information is kept in a secure location. Your records will not be released without your written consent, unless in those situations as outlined in the confidentiality section above.

Medical Records are locked and kept on site.

IV. Fees:

Private Fees for a 50 minute session are 120 dollars. Longer sessions vary depending on the time spent I may make arrangements with you to charge you at a lower rate or a sliding fee if you do not have any insurance.

V. Payments:

Payment is due prior to the session unless other arrangements have been made in writing. You are responsible for deductibles, co-insurance, and co-payments. All of this will vary depending on the nature of my relationship with your insurance company, and the quality of the insurance that you have. If I am a member provider of your insurance company, the fees above do not apply. Each insurance company sets a different fee schedule.

VI. Cancellations and Missed Appointments:

You will be billed 120.00 dollars for 50 min. sessions or $180 for 80 min. sessions not canceled with 24 hour notice accept in the event of an emergency. Insurance companies do not reimburse for failed appointments. Additionally I may terminate our relationship or give away your spot if you miss an appointment without 24 hours notice.

VII. Complaints:

You have a right to have your complaints heard and resolved in a timely manner. If you have a complaint about your treatment, policy please inform me immediately and discuss the situation. If you do not feel the complaint has been resolved, you may also inform your insurance carrier and file a complaint if you so choose.

VIII. Consent for Treatment

By signing below, you are stating that you have read and understood this 3-page statement and you have had your questions answered to your satisfaction. In addition, you are confirming that you received the HIPPA overview brochure.

I accept, understand and agree to abide by the contents and terms of this agreement and further, consent to participate in evaluation and for treatment. I understand that I may withdraw from treatment at any time.

Signature X__________________________ Date_______________________________________

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