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
Policies
Confidentiality/Privilege/Privacy- Normally information disclosed by you, your partner and/or your family during counseling will be kept strictly confidential and will not be revealed to anyone without your consent. If you consent to me consulting with another professional with whom you work, I will do so to the extent it is appropriate and useful for me to do. If you require your counseling records at any point, I will either provide copies of them to you, or, if I consider it more appropriate, I will provide a report of examination and treatment in lieu of copies of records, as allowed for in Florida Statute 456.057(6).
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 $225 per session for individual, couple, or family counseling. Counseling sessions exceeding the allotted time will be pro-rated and billed accordingly. In some instances, a discounted fee may be available, but this would be at the discretion of the counselor and client must meet the qualifications for said discount. Alternate payment structures will 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 telephone “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. Other than a genuine emergency or illness, you will be automatically billed for missed appointments unless you notify me 24 hours in advance. *The 24hr cancellation policy is a strict one as the scheduling system will lock scheduled appointments in at the 24hr prior mark. When you contract for the agreed upon hour, the office maintains the responsibility to provide it 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.
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.
A good therapeutic relationship is dependent on many things and it must be collaborative and appropriate for both parties. This is an ‘at will’ relationship and can be terminated at any time by either party.
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.