Please read through the following and agree by checking the boxes below.
Confidentiality: Please understand that all records, written information, or any electronic data are marked CONFIDENTIAL and are kept under lock and key. All sessions, including telephone, are confidential to persons outside of the therapy, unless otherwise agreed upon by your signed release. However I am required by law to report:
— When there is reasonable suspicion that the client presents a danger of violence to themselves or others, unless protective measures are taken.
— There is reasonable suspicion of child, dependent, or elder abuse.
— A legal proceeding and/or by court order
— per your signed release
Email: Email confidentiality cannot be guaranteed. If you choose to communicate with me by email for scheduling, billing, between-session inquiries, or any other reason, please be aware that it is possible that others can read or intercept this type of unencrypted material.
Client Agreement & Consent for Treatment:
Fees: I agree to make the full payment at the time of service by cash, check, credit card, or money order, unless other arrangements have been made. Checks should be made out to Adrianne Faye, M.A., LMFT. There will be a $30.00 fee for returned checks. If payment is more than 30 days late a 10% service fee (of the total bill) will be added on. Another 5%, (15% total) for every month after. If payment is not received within 75 days, I will have the right to collect payment through a collection agency. I understand that fees will increase yearly, and that I will be notified in advance. To make the most of our time together, please prepare your cash or check before your session.
Cancellation Policy: I agree to cancel appointments only in the event of extreme necessity. I understand I will be charged full fee unless I provide 48 hours advance notice. If this does not happen, you will be billed for the missed session. You can also try to schedule another appointment during that same week to avoid being charged for the missed appointment. Clients who are billing through insurance will understand that if they do not provide 48 hour notice, they will not just pay their co-pay, but will be responsible for the total insurance fee for. The payment will be equal to the total insurance fee amount for that session. I will wait 25 minutes in case you are late for your session. If I am late, I will make up for the time in another session. In case of an emergency, every effort will be made to reschedule your appointment within the same week.
Benefits and Risks: I acknowledge that it is my choice to participate in psychotherapy. I realize that the outcome of therapy depends upon my personal investment in the therapy process. If I decide to terminate treatment I will discuss termination before ending treatment. I understand that while therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, results in therapy cannot be guaranteed. Therapy must also be a priority for you in order for it to work. Please be determined to communicate with your therapist open and honestly, especially about issues that you have with the therapy itself, or with your therapist.
Termination of Therapy: You may discontinue therapy at any time. It is a good idea to have at least one final termination session with your therapist before you end therapy. You may review and consolidate your achievements, get closure, practice saying goodbye, discuss future goals, and/or receive referrals.
Legal Fees: I understand that if I become involved in legal proceedings that require the participation of Adrienne Faye, M.A., MFT, I will be expected to pay the hourly fee for all professional time spent towards my case.
Emergencies: I agree to go to an emergency room or call 911 if I am having a mental health emergency or feel in danger.
Availability: Your therapist believes that her excellent self-care and continuing education assures the highest level of care for you. Therefore she takes frequent vacations of varying lengths, and attends professional workshops and conferences. As a result, occasionally she will be unavailable for phone consultations. If you think you will need support when she is unavailable, please discuss it with your therapist in advance.
Before you agree below, please ask any questions you may have of this document by contacting me.
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