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Client Information

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Insurance Information

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Counseling Participation

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Primary Care Provider

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Outpatient Services Contract

Welcome to our group practice. This contract contains information about our professional services and business policies. Please read this carefully and think of any questions you may have so that we can discuss them. When you sign this document, it will represent an agreement between you and your therapist.

Psychological Services

Psychotherapy is difficult to describe and may be new to many people who are seeking treatment, as well as those who have had experiences in other practices. It varies depending on your needs and the issues that you bring with you to your sessions. There are many different approaches to counseling and we may utilize different ones to deal with the problems you hope to address. Because there aren’t easy answers to difficult problems, you will be required to be an active participant in your therapy. You will need to work on things we talk about during your sessions not only when we are together, but also after you leave and in between your sessions. This will help your treatment to be as effective as possible.

During your first few sessions, you will be asked questions that enable us to evaluate your situation and best plan treatment for optimal success. You may experience many feelings during the initial sessions as you will be asked to search yourself for
uncomfortable emotions such as sadness, guilt, anger, frustration, resentment, loneliness, etc. While it is difficult to allow such feelings to come to the surface, these feelings can lead to helping you to
learn more about yourself and the way you process your life. This can also help with your relationships, finding solutions to specific problems, and can significantly reduce your feelings of distress. Unfortunately, there are no guarantees. Much of this depends on your willingness to participate and your willingness to work on the issues that exist in your life.

During these first few sessions, you will also be able to evaluate whether or not you feel comfortable with your therapist and if you would like to continue therapy. Your comfort with your therapist is very important. We want you to be honest with us and we will return the honesty so that trust can develop with you and your therapist. Therapy involves a commitment on your part, of time, effort, and money so it is important that you feel you are able to make this commitment in order for therapy to work for you. That is why it is important to for you to feel
comfortable with your therapist. If you have any questions during therapy, we should discuss them as they arise. And, if you find you have problems with committing to the process, we will discuss that as part of your therapy to determine the best direction to follow.

Individual Sessions

We conduct the first session for one hour and the sessions that follow will last 45 minutes. After the second session, if you feel that there are differences between you and your therapist that make you uncomfortable, please feel free to bring them up. We can also discuss your treatment goals and the plan of approach which you therapist will be taking. We usually schedule one 45 minute session per week, unless more are needed initially. You will be
responsible at the onset of your session to pay your copay if you are using insurance or to pay the balance of the session if you are paying out of pocket. You are also responsible for informing us of any changes to your insurance as soon as you know of any changes. Without notifying us of changes, we will not be able to properly bill your insurance company and you may end up being responsible for more than your copay. If you need to cancel your appointment, we ask that you give at least 48 hours’ notice. Without 48 hours’ notice, you will be charged for the session at the rate of $60.00. If you and your therapist both agree that you were unable to attend
due to circumstances beyond your control, we may waive that fee. Frequent reschedules may result in a $30.00 fee depending on the reason. Our therapists’ time is valuable and we would like to be able to offer your time slot to someone else if you are unable to attend.

Group Sessions

At some point during the course of your treatment, your therapist may suggest that you join one of our groups as part of your treatment plan. These groups can be staggered with your individual sessions as discussed between you and your therapist. If your therapist suggests a group, then it would be highly recommended as a way to continue progress toward your treatment goals. Our groups focus on practicing some of the skills that are learned within your individual sessions, building coping skills, and increasing positive peer interaction. We require that if
you join a group, you attend all session and are responsible for the payment on sessions you do not attend, unless it is missed due to unforeseen circumstances. If you need to miss a group session, we ask that you give at least 48 hours’ notice. Without 48 hours’ notice, you will be charged for the session at the rate of $40.00. If you and your therapist both agree that you were unable to attend due to circumstances beyond your control, we may waive that fee.

Professional Fees

The Self Pay fee for services at this office are as follows.

Individual Therapy Couples/FamilyTherapy Group Therapy Court Ordered Substance Abuse Evaluations
With an LPC: $190 intake, $150 thereafter $225 intake, $175 thereafter $75 $250
With an LAC: $125 $150 couples/$175 family $75 $250

Crisis or Emergency Therapy sessions are $200 for the first 60 mins, and $50 for each additional 15mins.

Any phone conversation with a therapist lasting longer than 5 mins will be billed, including those with parents or family members of current clients. The first 5 min are free. 6-15min is $30. 16-30mins is $60. 31-45 mins is $90. 46-60mins is $120.

If you are using your insurance then your fee is your co pay and coinsurance, if you have any. If you have a deductible at the beginning of the year, you will be responsible for the reasonable and customary fee that your insurance company sets until your deductible has been met. Once your deductible is met you will pay only your co pay. If you need other professional services, such as report writing, telephone conversations lasting more than 5 minutes, attendance at meetings with other professionals, preparation of records, or treatment summaries, there will be a fee for these services. Please refer to our fee schedule for more details. If you are involved in legal proceedings which require our participation, you will be required to pay for our professional time even if we are called to testify by another party. All fees will be set by Lori O'Leary.

Transaction Fees

A $1.00 transaction fee will be added to all credit card payments. This fee will not apply to Health Savings
Account (HSA) cards, debit transactions, cash or check payments.

Billing and Payment

Remittance is due at the time of service unless we agree otherwise. You may not cancel an appointment because you cannot afford it without being charged the $60.00 cancellation fee or perhaps a $30 reschedule fee. If you cannot afford your co pay, we will attempt to make arrangements with you. Any outstanding balances that are owed by you, the client, may be turned over to a collection agency if payment is not received within 90 days or later. This would require that we divulge your personal information for this purpose only. By signing this form, you agree to the release of this information for collection purposes. Any questions you have can be brought up with Lori O'Leary on Fridays between 2 and 3 PM.

Insurance Reimbursement

All billing will be done by Lori O'Leary. If there are any issues with your insurance, Lori O'Leary will be the one to discuss these issues with. Please understand that we do not want to waste time during your session dealing with these issues. If you have issues with your insurance or with your co-pays, they can be discussed with Lori O'Leary on Fridays between 2 and 3 PM. If you have a deductible you will be responsible for meeting your deductible based on the reasonable and customary amount your insurance company contracts for. Each session
will count toward your deductible for that amount until it is met. If your insurance changes or your co-pay changes at any time, you must inform us immediately or you may be charged the full fee if we are unable to bill.

Professional Records & Confidentiality

The laws and standards of our professional ethics boards require that we keep treatment records. You are entitled to privacy of these records and this information. However, if at any time any therapist believes that their clients are in danger of harming themselves, harming someone else or if there is someone who may harm a client, we are obligated by law to notify the appropriate authorities. We must intervene if we believe there is any harm going to
come to anyone.

In general, the privacy of your records and the information shared between you and your therapist is protected by law and can be released only by your written permission. There are a few exceptions:

1. In most legal proceedings, you have the right to prevent me from providing any information about your
treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues require it.

2. There are some situations in which we are legally obligated to take action to protect others from harm, even ifwe have to reveal some information about a client's treatment. If we believe that an elderly person or a child is being abused or neglected, we must notify the appropriate state agency.

3. If we believe that a client is threatening serious bodily harm to another we are required to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking hospitalization for the client. If the client threatens to harm himself/herself, we are obligated to seek hospitalization for him/her or to contact their family members or others who can help to provide protection. These situations rarely happen in this practice. If an action is required, however, we will make every effort to fully discuss it with you before we take any action.

4. I understand that a copy of the HIPPA guidelines is available upon request.

Your signature below indicates that you have read the information in this document and have agreed to abide by its terms during our professional relationship.

Credit Card Authorization

I give my permission for O’Leary Counseling to keep the following card on file for the purpose of charging counseling services as outlined in my client services contract.

You will be informed before a charge is made and a receipt will be given upon request.

Reason and amount to be charged: Deductibles and copays (if applicable). Late Cancellation or No Show $61.00 ($60.00 cancellation fee + $1.00 CC processing fee). Late Cancellation for a group session will incur a charge of $41.00.

By signing this form I acknowledge the charges described hereon and assume full responsibility for said charges and agree to honor and abide by the terms of payment.