This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. Once you sign this, it will constitute a binding agreement between us.

SESSIONS:
The initial session involves my assessment of you and your assessment of me. During this time we both decide whether or not I am the right person to provide the services that you need in order for you to move forward in your life. Subsequent sessions will be scheduled based upon what is revealed during the initial session. My normal practice is to schedule weekly appointments through the end of the first month evaluate our progress then determine whether to reduce the frequency of sessions or remain on a weekly schedule.

Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advanced notice of cancellation (or unless we both agree that you were unable to attend due to circumstances beyond your control.

PROFESSIONAL FEES
My fee schedule is as follows:
Individual Sessions $90.00
Pre-Marital/Marital Sessions $110.00
Family Sessions $130.00
In certain case for clients without insurance or who are experiencing financial hardship, I may be willing to prorate my fee according to predetermined sliding scale, such fee to be determined by completion of the FEE AGREEMENT. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis for other professional services you may require such as report writing, telephone conversations that last longer than five minutes, attendance at meetings or consultations with other professionals which you have authorized, preparation of records or treatment summaries or the time required to perform any other services that you may request of me. In unusual circumstance, you may become involved in a litigation that may require my participation. You will be expected to pay for the professional time even if I am compelled to testify by another party.

BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to at the time these services are requested.
If you did not pay at the time of service, your account is more that 60 days in arrears, and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including collection agencies or small claims court. If such legal action is necessary, the costs of bringing that proceeding will be included in the claim.

INSURANCE REIMBURSEMENT
I accept most HMO and PPO insurance plans. I do not call o request authorizations. Prior to coming in for treatment you will need to call your insurance company to find out what your benefit coverage is and to obtain authorization for services. Verification of coverage is not a guarantee for payment by the Insurance Company. If your claim is denied by your insurance company it is your responsibility for payment.
***Most insurance companies do not make provision for premarital or marital counseling.

CONTACTING ME
I am often not immediately available by telephone; however my voice mail at 713-553-9811 option 1 is secure (confidential). I check my voicemail hourly and make every effort to return calls within a 24 hour period with the exception of weekends and holidays. If you cannot reach me, and you feel that you cannot wait for me to return your call, you should call your family physician or the emergency room at the hospital nearest you. Ask for the psychologist or psychiatrist on duty or call 911. If I am out of the office for an extended period of time, I will provide you with the contact information of a trusted colleague who you can contact if necessary.

PROFESSIONAL RECORDS
Both law and the standards of my profession require that I keep appropriate treatment records. You are entitled to receive a copy of the records, but if you wish, I can prepare an appropriate summary. Because these are professional records, they can be misinterpreted and/or upsetting. If you wish to see your records, I recommend that you review them in my presence so that we can discuss what they contain. Clients will be charged an appropriate fee for any preparation time required to comply with an information request.

MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents with the right to examine your treatment records. It is my policy to request an agreement from parents that they consent to give up access to your records. If they agree, I will provide them only with general information on how your treatment is proceeding unless I feel that there is a high risk that you will seriously harm yourself or another, in which case, I will notify them of my concern. I will also provide them will a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you and will do the best I can to resolve any objections you may have about what I am prepared to discuss.

CONFIDENTIALITY
In general, the confidentiality of all communications between a client and a licensed professional counselor is protected by law, and I can only release information about our work to others with our written permission. However, there are a number of exceptions.

In some judicial proceedings, you may have the right to prevent me from providing any information about your treatment. However, in some circumstances, such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it.
There are some situations in which I am legally required to take action to protect others from harm, even through that requires revealing some information about a client’s treatment.
If I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.

If I believe that a client is threatening serious bodily harm to another. I am required to take protective actions which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I may be required to seek hospitalization for the client, or contact family members or others who can help provide protection.
Should such a situation occur, I would make every effort to fully discuss it with you before taking any actions.

If you are a minor please download the agreement, have it signed by your legal guardian(s) and faxed back to our office at 713-667-4977.

If you don't have Adobe Acrobat to view the agreement you may download it by clicking here.