WALK TALK THERAPY SERVICES AGREEMENT NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.
WALK TALK THERAPY SERVICES
Walk Talk Therapy varies depending on the therapist, the client and the client’s particular situations and goals. There are many different methods I may use to deal with your particular situations and goals. In order for therapy to have the best outcome, you will have to invest energy in the process and work actively on things we talk about both during and between our sessions.
Walk Talk Therapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness, guilt, anger, anxiety or frustration when discussing aspects of your life. Psychotherapy has been shown to have benefits that can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. However, it is impossible to predict or guarantee what you will experience.
Our first session will involve an evaluation of your situation and needs and we will discuss goals you want to work towards. During this time, we can both decide if I am the best person to provide the services you need. Walk Talk Therapy can involve a significant investment of time, energy and money, so it is important that you select a therapist you are comfortable working with. If at any time you have questions about some aspect of our work together, please discuss them with me. If you decide that you do not want to continue in therapy with me, please tell me. If you want me to help you find another therapist or other appropriate resources, I will do so.
You voluntarily choose to participate in WALK TALK THERAPY because you believe it may be helpful to your own personal growth and development. You are not participating in WALK TALK THERAPY because of pressure from anyone else. I take full responsibility for communicating and maintaining my personal boundaries and acknowledge that I am not a personal trainer, medical doctor, nurse nor nutritionist.
You acknowledge that participation in WALK TALK THERAPY involves both known and unanticipated risks that could result in physical or emotional injury or damage to yourself or others. You understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of WALK TALK THERAPY. These risks include but are not limited to: emotional stress or trauma, strenuous and vigorous physical, mental and intellectual activity; the possibility of slips, falls, bruises, sprains, lacerations, fractures, animal bites or bee stings, concussions or even more severe life threatening hazards, including death.
I schedule 50-minute sessions with clients usually once per week at a mutually agreed upon time. If you arrive late for an appointment, we will only be able to meet for the remaining 50 minutes. Sometimes I will meet more or less than once per week if that is consistent with a treatment plan we both agree to.
If you ever need to cancel a scheduled therapy session, please do so at least 24 hours in advance. If you do not cancel a scheduled appointment with at least 24 hour notice or if you fail to attend a scheduled session, you will be expected to pay the full fee for that session, unless we both agree that you were unable to attend due to circumstances beyond your control.
My fee is $170 for each 50-minute session.
In addition to our regular sessions, I charge $250 per hour for other professional services you may need, though I will break down the hourly cost into 15-minute increments if I work for periods of less than one hour. Other services include report writing, telephone conversations we may have lasting longer than 15 minutes, attendance at meetings or consultations with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other professional service that you may request.
If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the complexity and difficulty of legal involvement, I charge $500 per hour for preparation, attendance, transportation at any legal proceeding.
BILLING AND PAYMENTS
You will be expected to pay the full fee at the time of each session unless we agree in advance. I accept payments by check, cash or credit cards. Payment schedules for other professional services will be agreed to when they are requested.
If you make a payment by check and your check does not clear due to insufficient funds or any other reason, you will be expected to reimburse in full for any related bank fees that is charged as a result.
You can contact me by telephone or email address listed above. I monitor my voicemail frequently and make every effort to return your call as quickly as possible, however, it is a non-urgent voicemail. Please leave your telephone number in your message to make it easier to respond to you. If you want me to use discretion when calling you or leaving a message for you, please let me know in advance. At times when I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary.
If you are in an emergency situation call Acute Psychiatric Services at (612) 873-3161, or your local emergency services at 911 or call or go to the nearest hospital emergency room and tell them what is happening. I will get back to you as soon as I possibly can in such situations, but I may not be able to get back to you immediately in all cases. You should immediately call 911 or the nearest emergency room and tell them what is happening.
The laws and standards of my profession require that I keep treatment records. You are entitled to examine and/or receive a copy of your records if you request it in writing unless I believe that seeing them would be emotionally damaging, in which case I will send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/ or be upsetting to people who are not mental health professionals. In order to see your records, we will need to discuss the contents together. I reserve the right to charge you for the costs of copying and sending your records if you request them.
You certify that you have adequate insurance to cover any injury or damage caused while participating in WALK TALK THERAPY or else you agree to bear the costs of injury or damage to yourself. You certify that you have no medical or physical conditions which could interfere with your safety at WALK TALK THERAPY, or else you are willing to assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition. You have sought the advice of a physician and believe you are in good health.
Your mental health information is confidential; however therapists are mandated reporter’s which means that in all certain circumstances, I am required by law to release information without your consent.
These situations are described below. Please read these situations and feel free to ask any questions about them.
- If you make a specific threat to harm yourself or someone else (and the risk of danger is deemed imminent), I must take appropriate steps to protect you or warn the appropriate parties.
- If I suspect you have physically or sexually abused or neglected a child or vulnerable adult, I must make a report to the proper authorities. This includes some cases of domestic abuse when a child is exposed to weaponry or is physically threatened and/or used as a weapon.
- If you are pregnant and using a controlled substance, such as heroin, cocaine, phencyclidine, methamphetamine, or their derivatives.
- When there is a court order to release your records to the legal authorities.
Because WALK TALK THERAPY is conducted outdoors in public places, you understand that there are confidentiality risks and consequences to your participation. One of us may encounter another person that we know and another person may overhear what we are saying.
While I am not an attorney, please discuss any questions or concerns you have about confidentiality with me at any time. If you have specific legal questions about the laws regarding confidentiality, the exceptions, and how it may relate to your situation, please seek formal legal advice from an attorney.
OTHER CLIENT RIGHTS
If you want, I will discuss with you more details about any of the following:
- You have the right to request and receive from me confidential communication of your protected health information by alternate means or at alternative locations. For example, you can request that I send any correspondences to an address other than your home address if you don’t want a family member to know that you are in therapy with me.
- You have the right to request that I change information in your record. I require such requests in writing along with your reasons for your requested changes. I may deny your request.
- You generally have the right to receive an accounting of any disclosuresIf you want, I will discuss with you more details about this process.
I reserve the right to change the policies, practices and procedures described in this document. I will notify you in writing of any significant changes. By signing this Therapy Agreement, you are indicating that you have received and read the information in this document, you have discussed the contents with me to your satisfaction, and you agree to abide by its terms during the course of our professional relationship.
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