Counseling Agreement and Informed Consent
Dear New Client:
As we begin working together, it is important that you understand my policies and procedures. Please read this document carefully, bringing in any questions, concerns, or comments about the information. This document is for you to keep for your reference. After you have reviewed this agreement, please fill out and return the Counseling Agreement and Client Intake form, including your signature, stating that you have received and understand these policies and procedures.
I am a licensed Marriage and Family Therapist, #200949, and a Licensed Professional Counselor supervisor, #61033. I received a Doctorate degree in Marriage and Family Therapy from St. Mary’s University in 2007. I have been providing psychotherapy, neurofeedback, biofeedback, and hypnotherapy to couples, families, adult individuals, and adolescents since 2002.
Adults: Everything that we talk about in our sessions will be held confidential and privileged. No one will know the content of our counseling sessions unless you tell them or sign a release of information allowing me to disclose specific information. Exceptions: I may need to break confidentiality if you are going to hurt yourself (contemplating suicide) or someone else (Homicide, child, dependent or elder abuse). In these cases, I am required by law to contact public authorities, processionals or other affected persons. These may include your family or friends if your life is threatened or others whose life is being threatened. I will act discreetly and wisely on your behalf, should any of these circumstances arise. The intent of my actions will always be to serve in your best interest.
Children and Teenagers: My first responsibility is to honor our confidential relationship; we need to trust each other. Therefore, specific information will not be shared with your parents or others, unless you give me specific permission to do so. I may, however, share generalities with your parents and offer helpful guidance to your parents and other supportive persons. Exceptions: To protect you and help both you and your family to address and change destructive behavior, I am responsible for reporting to the appropriate agencies in the following events:
Sexual activity if you are under the age of 14,
Physical, sexual, emotional and/or psychological abuse
Potential for suicide
Potential for homicide
Should the need to report arise, I will try my best to discuss it with you at the time, as I feel that honesty is crucial to our work together. The only other instance in which confidentiality would be broken is if I am required to testify or submit my records, but this can only be done if I receive a court order.
There are several ways that you can reach me outside of our sessions. Communication by telephone will be important for both of us. If you need to discuss billing or scheduling, please call my wife at (210) 415-2542, and she can take care of you. If you need to speak directly to me, you may reach me at (210) 831-1282. This is my cell phone number. During business hours, Kate or one of my interns will answer this line, and pass on any information you need me to know. If you would like to speak with me, please let my staff know, and I will do my best to return your call as soon as possible.
Please understand that after office hours, I am spending time with my family. This line of work does require that I return calls during my personal time, however I will not handle billing or scheduling outside of business hours as these are not emergencies. I ask that you please be respectful of my personal time and limit phone calls to ten minutes or less. After ten minutes, if we continue the conversation, I will charge you a prorated fee at your normal session rate.
Please do not contact me by text message, as this form of communication is not secure or HIPAA compliant. I can receive e-mail at my secured HIPAA compliant e-mail: email@example.com, or by mail at 13300 Old Blanco Rd Suite 260, San Antonio, TX 78216. If you are ONLY e-mailing about billing or scheduling, or you would like general information, please use Kate's e-mail at firstname.lastname@example.org.
I am not a crisis counselor, and I do not have the infrastructure to provide crisis counseling. If you are experiencing a crisis, please leave me a message and I will return your call as soon as I am able. If you are experiencing a life-threatening emergency, call 911 immediately. If you let me know in advance of a potential crisis situation, I can provide you with 24-hour hotlines as resources to assist you until I am able, and I will be watching for a call. If you are feeling suicidal or homicidal and I am not available, please call the police as well as someone close to you to support you until help arrives. During a crisis, I will do my best to see you in person as soon as possible. Due to my limited office hours, we may need to set up a phone or video conference appointment. For all video conferencing I use doxy.me, which is a secure, HIPAA compliant telehealth platform. Phone and video conferencing appointments will be based on the same hourly rate as an in-office session.
My goal in therapy is to help you work everything out without the need for the courts, and your records and our discussions are confidential and cannot be shared without a court order. I do not act as an expert witness on a regular basis, and am not specialized in forensic psychology. Appearing in court and preparing my records for court are part of our therapy contract, and any time spent in this pursuit will be billed to you at your normal session rate. As required by law, I will appear if you choose to go to court for any reason and I receive a court order. However, my practice would have to close up for the day if that is the case, and I would have to cancel my appointments while I am required to be at court. That being said, you will be charged a minimum of four hours at your normal session rate on the day of the court appearance, and an additional $200 an hour after that. This includes the time it takes me to drive to and from the courthouse, parking, etc. If you believe a lawsuit or other court case may require my notes or my appearance, I ask that you please inform me as far in advance as is possible.
When I am on vacation or at a conference, I will let you know in advance as well as leaving a message on my voicemail. I will leave the name and number of a qualified colleague to assist you if needed during my leave. If you are in crisis prior to my leave, I will consult with my back up regarding your case (with your permission of course) and give you their contact info. I ask that you keep me in mind when you make vacation plans as well by letting me now the dates you will be gone well in advance, so that I can plan accordingly.
Sessions may be scheduled three (3), two (2), or one(1) time a week, every other week, or as needed, and they will last 50 minutes. If you need more than 50 minutes, please let me know in advance and I will do my best to accommodate you. Sessions that run over 50 minutes will be prorated on top of your normal session fee. I would like you to value each moment of our work together and be present for the full appointment, so please arrive promptly. You will be billed for the full session, even if you are late. Appointments are often scheduled back-to-back, and I usually cannot run over without sufficient prior notice. Occasionally, I may be late or run over from a previous session. Should that happen, you would have your full session unless other arrangements are made. If I am unable to make up the time, your session will be prorated.
I have a 24 hour cancellation policy. If arrangements are not made at least 24 hours in advance, you will be charged for the appointment, as I cannot fill your appointment time. This policy applies even when you or your child becomes sick. I understand that illness is never planned; however, I hold your spot and do not schedule another client in that slot until I am given notice. I prefer not to charge you for an unused session. If you are canceling an appointment, please call mKate at (21)415-2542. If we do not answer, please leave your name, a phone number I can reach you, and any instructions for me on my voicemail. If you do not hear back from me within two hours, please call Kate again at (210)415-2542 to confirm receipt of your message.
I do understand that emergencies come up. I will do my best to accommodate these emergencies, being as flexible as I can. However, I still incur my normal expenses whether you show up or not, and I have often begun preparing for your session within the 24 hour window. Should you cancel less than 24 hours in advance, you have the option of rescheduling later in the week if an appointment is available. If that is the case, and you keep the second appointment, I will not charge you for the missed appointment. Let me emphasize that I do not like to charge for unused appointments and will do my best to avoid that case.
No Show / Late:
If you are late by more than 15 minutes and have not called to let me know you are on your way, I will consider you a “no show” and you will be charged for the appointment. At that point, I may leave my office. If you are running late, please let me know and I will wait until you get there.
24-Hour Clean and Sober Policy:
I ask that you come to sessions at least 24 hours clean and sober. This is to ensure that our work can be accomplished with a clear mind. This is especially important if you are coming for neurofeedback or biofeedback, as the success of our session can be compromised if you are under the influence. If you come to a session under the influence, I reserve the right to end the session and charge you for the appointment.
Children and Your Counseling Time:
Your counseling session is your own, special time; a period when you can concentrate on personal issues without any interruption. I request that young children do not accompany you to counseling sessions unless they are specifically included in your scheduled sessions, or the child is my client. If an emergency occurs and you must bring your child with you to a session rather than miss it, please call and let me know. It is then important to be considerate about the issues discussed with children in the room.
Statement of Intent:
It is my intent to facilitate the growth and development of you and your family (if present) to the very best of my ability. Further, I want you to feel completely satisfied with the services that I offer. If at any time, you feel that I am not fulfilling this intent in any way, please tell me so. I encourage and appreciate honesty. Part of the work we do will be based on the creation of a relationship where conflicts can be discussed openly so you can then apply these skills to your life outside my office.
Process and Termination:
Clients often seek counseling in times of crisis and then stop abruptly when everything calms down and the problem feels “fixed.” The real “work” in counseling is not done during crisis intervention, although it can start there. Most termination of therapy work is done over the course of a few sessions. I request that you let me know when you feel as though our work is getting close to an end rather than stop abruptly or continually canceling and rescheduling. Saying goodbye is hard for most people. I ask that we work together on ending your relationship in a healthy and respectful way. This would include a termination process where we discuss the progress and gains made in counseling, how to continue with them, and the establishment of resources for the future. A goodbye session (or preferably sessions) is especially important for children as they often wonder what happened when they are pulled from counseling abruptly. Regardless of what goes on among the adults, children benefit from saying goodbye.
Initial Consultation (1st session)- Because I spend 2 hours with you for the initial consultation, the charge is $200 ($100 per hour). All other sessions are 50 minutes.
All services for an individual (Talk Therapy, Biofeedback, Neurofeedback, Hypnosis, etc)- $125 per 50 minute session. Each hour booked is considered a session. The only exceptions to this rule are if neurofeedback packages are purchased, in which case there is a discount included. These packages are posted on my website at www.icnssa.com under pricing and insurance.
Couples and family sessions- $175 per 50 minute session. This is inclusive of all parties present, so whether there are 2 people or 10, the charge is $175. I charge more for these sessions because I do not charge per participant and the sessions require even more preparation on my part than individual sessions do.
Assessments- The Quantitative EEG normally costs $750 and includes the fees for the report and in-house analysis as well as the review session. If a neurologist report is deemed necessary or the data cannot be analyzed in house due to a low quality recording or evidence of seizure disorder, then a $100 charge will be added to the cost to cover those fees. The fee for this assessment can be paid in 2 installments, one at the time of data collection, and one when the results come back. The minimum first payment is $375.
The IVA+Plus, a Continuing Performance Test which is part of the diagnostic process for ADD and processing disorders, costs $200 and includes a pre-treatment and post-treatment administration. It is available by request.
Payment Methods and Policies:
Payment in full is required at time of service. We accept the following:
Cash/Check, Visa, MasterCard, Discover, American Express
For all clients, a credit card is required on file with us in the event of missed sessions. It will not be charged except in the case of missed appointments where we can not get ahold of you by end-of-day, and your information will never be shared with any third party. If payment for a session is made by check, and the check bounces, the owed amount will be charged to the credit card plus a $35 returned check fee. We are happy to accept your checks, however we reserve the right to refuse checks for appointments following a returned check.
I agree to maintain the rates in this agreement for six months following your Initial Consultation, and at that time, the rate may be revisited and subject to change.
If you have not arrived for your appointment within 16 minutes after your appointment time, you will be charged for the missed appointment, and if your appointment runs over the time allotted, you will be charged $2.50 per minute unless I waive this fee.
I do not accept insurance because I strive to provide the most effective and comprehensive client care possible. Over the years of working with clients, I have found that the session limits, confidentiality issues, and pathology “labels” associated with taking insurance can pose more of a hindrance to good client care than it does a benefit. While session frequency and the number of sessions should be a collaborative decision between the client and the therapist, insurance companies frequently impose a session limit or require a specific treatment. This can undercut the effectiveness of the overall therapy process, as well as remove the freedom of choice and control a client has over his or her mental health care.
In addition, insurance companies require a diagnosis code, and many times, a treatment plan for each client. This can result in what feels like an invasion of privacy as well as a feeling of being “labeled” or “pathologized.” Because my goal is to work in a holistic and non-stigmatizing manner, the requirements of insurance can pose a conflict of interest.
Finally, I view mental health treatment as not only an intervention but also a form of prevention. Even though paying out of pocket may feel overwhelming, when viewed as an investment in one’s future, it can become a priority. Research indicates that those who invest both time and money in mental health tend to have reduced healthcare costs as well as increased productivity and earning potential in other areas of their lives.
Please understand that while we do everything in our power to protect your PHI, posting comments to our blog, liking our Facebook page, and any other social media interaction with us on your part is public information and is not considered Protected Health Information. Please DO NOT send us personal information via Facebook, Twitter, Linked In, or any other publically accessible forum, including Facebook Messenger. By using these elements of our site you are accepting the public nature of your comments and any other information you provide via these methods of communication.