Important Information about becoming a Client
Individual appointments that are not cancelled at least 24 hours in advance will be considered a late cancellation and charged the full fee. Although the minimum cancellation time to avoid late charges is 24 hours, I would appreciate your giving me as much time as possible so that the hour does not go unused. To cancel an appointment, you may leave a message on my Voicemail (513-535-8025). I would appreciate it if all non-emergency calls would be made before 11 p.m. or after 7 a.m.
The fee for a 50-minute session of individual psychotherapy is $125. The fee for Gottman marital/relationship therapy is $900 for the six (6) hours of the Intake Process and $125 for subsequent 50-minute couples therapy sessions. All billable professional time such as lengthy telephone calls and report writing will be billed at the hourly rate.
3. Payment of Fees/Nonpayment of Fees
I would prefer that payment for each session be made at the time of service. If you need a receipt periodically for reimbursement from a medical savings account, please let me know. Any unpaid balances must be paid in full upon termination of therapy. I reserve the right to send outstanding balances for collection. I use I. C. Systems, Inc., a St. Paul, Minnesota collection firm. A 33% collections charge will be applied to outstanding balances sent to I. C. Systems. Part of their service is to report the outstanding amount owing to all major credit companies.
Although I choose not to participate in insurer’s preferred panels, and therefore I do not bill insurers, I will be glad to complete insurance forms for you to file with your insurer if you so choose.
5. Duty to Report Abuse or Neglect
Under Kentucky law [KRS 620.030(1)] “all persons, regardless of background or training, must immediately report either when they “know” or have “reasonable cause to believe that a child is dependent, neglected, or abused.”
6. Duty to Warn
Under Kentucky law, if a client communicates a threat of violence against another person, I am required to warn that other person and to notify the local police department. Since duty to warn can be interpreted as duty to protect, in the event that I believe that you are a suicide risk, by signing this you are giving me permission to notify an emergency contact who would assume responsibility for you.
I have read and understand the above information