Important Information about becoming a Client

1. Appointments/Cancellations

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. 

2. Fees

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. 

4. Insurance

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.”
Under Kentucky law [KRS 209.030(2)] the duty to report spousal abuse applies to any person who has “reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation.”
Thus, I am required by law to report when I have reason to suspect that a child is threatened with abuse or neglect, and I am required by law to report when I have reason to believe that an adult has actually been abused, neglected, or exploited.  Under Kentucky law I am also required to turn over copies of records in the event that an abuse investigation occurs.

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

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