Building Strength for Life and Love™

Informed Consent for Treatment (Couples) GF

Informed Consent for Treatment (Couples)

Please read and fill out this Informed Consent for Treatment prior to our first session.

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  • Financial Policy

  • Office Visits:

    Fee payment for each session is due at the time of service unless arrangements are made. Fees are payable by credit card, check, or cash. Receipts will be given for all payments. Clients will be given 2 months notice of any increase in fees. You are encouraged to discuss the above financial matters with the therapist at any time. The payment of fees for counselling is part of the client/therapist relationship. The current fee is $150 per 1.5 hours couple session.
  • Cancellations:

    Appointments must be cancelled at least 24 hours in advance of the scheduled appointment time. Failure to provide 24 hours notice will result in a missed appointment charge of the full fee for the time scheduled which will be charged to your credit card. Late cancellations due to medical or other emergencies will not be considered as missed appointments. Clients fill out a credit card authorization form prior to the first visit. Therapist keeps this information on file in case of missed sessions.
  • Telephone Conversations:

    Fees for 15-minute conversations between the therapist and client are included in the fees paid for routine office visits. Therapist’s office is equipped with a confidential voice mail system that allows Client to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room.
  • Insurance Coverage:

    Therapist is not a contracted provider with any insurance company or Medical Services Plan. Should Client choose to use his/her insurance, Therapist will provide Client with a statement, which Client can submit to the third-party of his/her choice to seek reimbursement of fees already paid.