Confidentiality/Therapy Cancellation Policy & Fees

Each partner in a couple must complete the Confidential Couples Counseling Intake form and initial The Limits of Confidentiality/Therapy Cancellation Policy & Fees form.

Please initial and submit this form prior to your visit.
  • Legally Mandated Disclosures

    Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows: Legally Mandated Disclosures 1. When a client discloses intentions or a plan to harm another person, the mental health professional is required by law to warn the intended victim and report this information to legal authorities 2. If the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. 3. Suspected child abuse or neglect is reported to Child Protective Services. 4. Suspected elder/dependent adult abuse or neglect is required to be reported to Adult Protective Services.

    My fee is set per therapy hour (50 minutes) whether for one person, a couple or a family. Partial hours are prorated. Fees are payable at the conclusion of each session. My fee per therapy hour is $195.00

    Our office is happy to assist you in filing your insurance claims by providing a monthly statement of services upon request.

    I make every effort to honor all time commitments, and ask that you reciprocate. In the event that you cannot keep your scheduled appointment and must cancel within 24 hours of your appointment time, you have three options: *You may reschedule your appointment for the same week when time is available. *We can conduct your appointment over the phone. *You can opt to pay for the missed appointment. EMERGENCY/TELEPHONE CONSULTATIONS Should you require telephone consultation in addition to your regularly scheduled appointment, you can reach me by leaving a message on my office voice mail. Messages are picked up between the hours of 7am and 5pm. Telephone sessions will be billed on the same basis as a prorated office visit. For crisis situations that require immediate attention please call the Mental Health Crisis Hotline at 800-479-3339. CANCELLATION POLICY If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full fee is charged for missed appointments or no show cancellations with less than a 24 hour notice unless due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for or cancel an appointment. Thank you for your consideration regarding this important matter.
  • Please remember to complete the Couples Intake form which is found on our Forms Menu.