Therapy Agreement

The type of therapy you will receive varies according to your particular needs. Normally, at our first and/or second session, you and I evaluate together what type of therapy will be appropriate and what issues to target. In order for you to derive maximum benefit from your therapy session, it is in your best interest for you to arrive for all appointments at the appointed time.

Confidentiality:
All information concerning therapy services rendered by this therapist is confidential, with the following exceptions:
❖ A legitimate subpoena by a court of law requires the release of information specified by that subpoena.
❖ Statements of intent to harm oneself or another may result in notification of appropriate authorities and/or intended victims.
❖ Information concerning suspected child or elder abuse or neglect must be reported as mandated by The State of Virginia, where I am licensed.
Please initial indicating that you have read and understood this section:*
Office Policies:
❖ Therapy sessions are scheduled for 50 minutes.
❖ As previously stated, it is in your best interest to be on time for your appointment; the time for your session has been set aside specifically for you. Appointments will not be extended to compensate for client lateness.
❖ Payment is made via the website prior to appointments. Although a fee agreement has been made at the initial contact, this is subject to change. Notice of approximately two weeks will be provided.
❖ Please provide 24 hours notice for cancellation of appointment; I will provide you with the same. If you experience sudden obligations or needs that would interfere with our session, please let me know as soon as possible. Our goal is to be respectful of each other’s time.
❖ If you have received a reduced fee schedule, refunds will not be given for missed sessions. However, you can have a make-up session for the time missed, the make-up session should be in the same week as the missed session, wherever possible.
Please initial indicating that you have read and understood this section:*
Telephone Calls and Messaging:
❖ You can use the email address to communicate with me. I will respond to your message as soon as possible, generally within 24 hours.
❖ If you are experiencing an emergency episode, please call 911 or a Crisis Hotline such as: Suicide Hotline: 1-800-784-2433.
Dialing 211 on your phone will bring you to a national human service call center.

BY ENTERING MY NAME BELOW, I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS AGREEMENT AND I REPRESENT THAT BY SUBMITTING THIS DOCUMENT I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL TERMS HEREIN.
- Client (or Guardian) Signature:*
- Date*
  MM slash DD slash YYYY
Please Email a copy to me.
- Yes, please send me a copy.
- No, thank you.
Email
Name
This field is for validation purposes and should be left unchanged.