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Forms & Policies

Forms

Please take a moment to print and complete these forms prior to your first scheduled session so that we may best use our time together. Downloadable informed consent and intake 

Informed Consent Form 

Intake Form

Policies

Confidentiality - Normally information disclosed by you, your partner and/or your child during counseling will be kept strictly confidential and will not be revealed to anyone without your written consent. It is important for you to know that there are some exceptions to confidentiality however. If an exception should arise, I will make every reasonable effort to inform you of the necessity to break confidentiality, before doing so.

Exceptions to Confidentiality & Privilege :

1) If you threaten harm or death to yourself or another person, I am legally, ethically and morally required to take action to protect the safety of the threatened person. Actions could include; informing the intended victim, arranging for hospitalization for you and/or your child, notifying family or support system, or alerting law enforcement.

2) If abuse or neglect of a child, aged person, or disabled person is known or suspected, I am required by Florida law to report my concerns to the Department of Children and Families.

3) If I were to receive a legally binding Court Order for your counseling records or for my deposition or court testimony, I would be required to comply.

4) If you or your child are in counseling or are being evaluated by Order of the Court or as condition of continued employment, I may be required to provide the Court or the Employer with reports, documents, or testimony.

Fees & Payment - Counseling fees are $175 per session for individual, couple, or family counseling. Counseling sessions exceeding the allotted time will be pro-rated and billed accordingly. Alternate payment structures may be made on a case by case basis and will require a discussion prior to the session. Group counseling fees are dependent upon the size and length of the group. Telephone consultation and other professional activities rendered on behalf of the client are also billed per hour; however there is never a charge for short "check-in" or scheduling coordination. Clients will be asked for a credit or debit card to be placed on file for their automatic payment convenience as well as in order to bill for pending payments that may be due. Payment is due at the time of service unless otherwise arranged in advance. Payment must be made by check, cash or credit card. Missed appointments will be automatically billed unless cancellation has been made 24 hours or more in advance. *The 24hr cancellation policy is a strict one as the scheduling system will lock scheduled appointments into the system at the 24hr prior mark. Additionally, when you contract for the agreed upon hour we maintain the responsibility to provide the office for you and will have to turn away others for service during that hour as a result. In circumstances where problems are encountered in receiving payment for services rendered, you may be billed additional charges to cover the cost of time and expenses incurred to obtain payment

Insurance/Managed Care - I am a fee for service provider and as such am not covered by insurance panels and/or Managed Care. Please see FAQs for the rationale behind this. In many cases, you may request a receipt for sessions billed and submit this to your provider for your predicated level of reimbursement depending on your policy. 

Licensing and Ethics - I am a Licensed Mental Health Counselor in the state of Florida LMHC-11942. As such, I am regulated by the Florida Department of Health 491 Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling. I am professionally insured under the Healthcare Providers Service Organization and, as a member of the American Counseling Association, I adhere to the ethical principles of this organization. A copy of the ethical guidelines may be found on this organization’s website: www.counseling.org .

Emergencies/Crises/Contact  - I check my confidential voice mail several times per day and I will make every effort to return your call at my earliest opportunity. However, if you are unable to reach me or if you have an emergency, immediately call 911, go to a hospital emergency room or seek the necessary services at your disposal. Your safety is my primary concern and I will be in touch as soon as possible. Brief text messaging may be used for the purpose of scheduling and quick clerical check-ins, however it is not an appropriate conduit for therapeutic conversations of considerations, these are best left to our next scheduled session. In order to model appropriate work/life balance, calls and texts after 7pm or on weekends will most often not be returned until the next business day, so please take that into consideration.

Payment

This button will redirect you to paypal in order to pay for your session. You don't need a paypal account to pay however, as all major credit cards are accepted. There are no fees associated with the payment - just an offered convenience. Many thanks.