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TRUEiCare Mental Health Clinic

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This document is provided for informational and educational purposes only and should not be considered legal advice

Counselor-Client Service Agreement

Welcome to my practice. This document contains important disclosure information about my professional services and business policies. It was created to accord with the TexasAdministrative Code and the Revised Code of Texas. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you submit this document, it will also represent an agreement between us. We can discuss any questions you have when you submit them or at any time in the future.

By submitting this form, I understand and agree to the following:

Counseling and Psychotherapy Services

For the purposes of this document, “counseling” and “psychotherapy” are considered to be equivalent terms. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. The American Counseling Association defines “counseling” as a “professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.” As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Counseling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of counseling often requires discussing the unpleasant aspects of your life. However, counseling has been shown to have benefits for individuals who undertake it. Counseling often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. Please note, I am not qualified to prescribe medications. If you have a need for a referral to a prescriber, I can discuss options with you, both at River Valley Psychological Services (we have psychiatrists and nurse practitioners on staff) or elsewhere.

My Professional Education and Training

OK I'm going to be honest here, I don't have any as a therapist/counselor, but I imagine you will :)

My Therapeutic Orientation

I strongly believe in individualizing treatment, and thus my approach to working with clients may differ according to the needs and preferences of individual and unique clients. I also select different approaches based on age, developmental level, and modality (individual, couple, family). When working with children and adolescents, I tend to conceptualize treatment from a Family Systems perspective, and thus often include parents and other siblings in counseling sessions. If working individually with elementary age children (5 to 10 years old), I tend to use Child-Centered Play Therapy based on Gary Landreth’s model. If working individually with pre-teens and adolescents (11-18 years old), I tend to use a mixture of more directive and structured approaches such as Cognitive-Behavior Therapy, Dialectical Behavior Therapy, and Solution-Focused Therapy, alongside relational approaches such as Interpersonal Therapy. In couples work, I often use Gottman Method Couples Therapy. When working with individual adults, I tend to prefer a Psychodynamic and Attachment-based approach to help individuals connect current relationship and behavioral patterns to their past history. There are some commonalities in how I approach treatment with every client I work with. For example, I take a strengths-based approach and attempt to highlight the client’s abilities even when working on problems. I also value basic listening and the importance of the client being heard, understood, and validated.

Proposed Course of Treatment

Because each client is a different and unique person bringing individualized problems to work through, the proposed course of treatment may differ for each person. With that in mind, I propose the following for the initial course of treatment. The first 1 – 4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that I often require parents to attend the first four sessions when I am working with a child or adolescent client, before we make collaborative decisions about whether individual or family therapy is indicated.


The initial intake session lasts for 60 minutes, and subsequent sessions last for 60 minutes. Appointments will occur once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your co-payment (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

Professional Fees

The standard fee for the initial intake is $185.00 and $130.00 for each subsequent session. If you are paying at the time of service with no insurance billed, this is denoted as “simple-care” with the charged amounts of $150.00 for the initial intake, and $120.00 for subsequent sessions. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash; I am not able to process credit card charges as payment. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, or the time required to perform any other service which you may request of me. Please note, I do not provide custody evaluations or evaluations of legal competence to stand trial (e.g., not guilty for reason of insanity). If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, my billing service and I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.


Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. Reimbursement may be dispersed as a “bundled payment” for the calendar year, or on a session-by-session basis. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your counseling. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the Diagnostic and Statistical Manual of Mental Disorders. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, as needed). Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By submitting this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance. Because of these confidentiality concerns, some clients elect to pay out-of-pocket (i.e., not use health insurance benefits). I am open to discussing your payment preferences, and recommend doing so during our first session. In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the client. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount, that must be paid by the client before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by my provider contract. If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

Professional Records

I am required to keep appropriate records of the counseling services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request (i.e., release of information form).


My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. In brief, I will attempt to keep all information you disclose to me confidential, with some notable exceptions outlined below:

  • You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. In such cases, I must act to protect you from harming yourself. For client and adolescent clients, I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be, and also act to protect you from harming yourself.
  • You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In such cases, I must inform the person who you intend to harm. For child and adolescent clients, I must inform both your parent or guardian, and the person who you intend to harm.
  • You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In such cases, I will need to use my professional judgment to decide whether I need to act to protect yourself or another person from harm. For child and adolescent clients, I will need to use my professional judgment to decide whether a parent or guardian should be informed, in addition to deciding whether I need to act to protect yourself or another person from harm.
  • You tell me you are being abused physically, sexually or emotionally – or that you have been abused in the past. In this situation, I am required by law to report the abuse to the Texas State Department of Social and Health Services.
  • You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.
  • You waive your privilege to confidentiality if you bring charges against me. You have been provided with a copy of the Notice of Privacy Practices and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

Contacting Me

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. For scheduling concerns, you may call the office at River Valley Psychological Services. For urgent matters outside of business hours, you may call River Valley Psychological Services on-call services. For emergencies, dial 911. For example, if for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, either 1) go to your Local Hospital Emergency Room, or 2) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.

Contacting the Texas Department of Health

If you believe that I have acted unprofessionally, you have the right to contact the Texas state Department of Health so you may obtain a copy of the acts of unprofessional conduct listed under RCW 18.130.180. The contact information for reporting is: The Texas State Department of Health, Health Professions Quality Assurance Division, at P.O. Box 47869, Olympia, TX 98504-7869. Phone: (360) 236-4902. Mondays through Fridays, 8am to 5pm.

Other Rights

If you are unhappy with what is happening in counseling, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. You have the right to choose treatment, to choose your counselor and treatment modality that best suits your needs, and to confidentiality (with some notable exceptions listed above).

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