1.Initial 45 minute sessions are $225.00. Following sessions of 45 minutes are $180.00. Add 60 minute session for $234.00. Group session fees are $50.00 per week payable in advance monthly. I no longer discount my fee for couples or family sessions regardless of insurance contracts. Payment is due at the time of therapy services and I prefer you have your payment ready at the beginning of sessions. Typically, sessions are scheduled on a weekly basis or more often if needed.

2.Your signature below signifies that you have received a copy of the HIPPAA form; Policies and Practices to Protect the Privacy of Your Mental Health. (Copies in Office)

3.No show and cancellation policy. The full session fee of $170.00 will be charged for missed appointments without 48 hour notice. Please let me know in advance. Managed care will not pay for this charge.

4.You are ultimately responsible for all fees. Should your account become delinquent, you acknowledge by your signature below that you are responsible for all legal fees, court costs, and collection fees required to recover any delinquent fees. It is the policy of this office that fees are due at the time of service therefore accounts which become more than thirty days old are considered delinquent and will be turned over for collection. Please stay current with your payments to protect your credit.

5.If you have an emergency, you may call or text me at (512) 636-6810 and leave a message. Your call will be returned as soon as possible. If you have a true emergency, call or go straight-away to the nearest hospital. Calls lasting over three minutes will be charged at the rate of $4.00 per minute (the same as session time). If emergency calls begin to occur on a regular basis, this generally indicates that office appointments need to be scheduled more frequently. In the event you are unable to reach me because of technical failure of communication equipment and you feel your life is in danger, go to the nearest hospital, police station or call 911.

6.Confidentiality: any communication between you and this therapist and any records maintained by the therapist are confidential and may be disclosed only with your written permission. There are certain legal limits to confidentiality which include: (a) records that can be subpoenaed regarding mental condition of the client, child custody suits and malpractice claims, (b) the therapists duty to warn if there is a imminent threat to the client or if the client threatens to imminently do harm to another, and (c) when there is a threat of physical or sexual abuse of a child, elderly person or vulnerable adult person.

I have read and understand and agree to the above policies.

Signature_________________________________ Date _____________________________