Rita Haley, LMHC
Therapist-Client Agreement Contract
Therapy Services Contract
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. We will then review it together. When you sign this document, it will represent an agreement between us.
Psychotherapy Services
Psychotherapy is not easily described in general statements. There are several different reasons, contexts, situations, concerns and symptoms which motivate an individual to seek psychotherapy. Thus, there exist a number of different treatment modalities to address a variety of needs and symptoms. There is no one size fits all when it comes to psychotherapy.
Psychotherapy does require active participation on your part, and a commitment to your treatment. In order for treatment to be successful, you will have to attend your scheduled appointments, participate in the session and do “homework” outside of sessions.
Psychotherapy does not guarantee you will feel better, your problems will be resolved, your relationships will be improved, etc. However, research demonstrates that those who participate in a cognitive-behavior therapy feel more empowered, less distressed, better able to cope with stressors, and thus better able solve problems in their life, resolve differences in their relationships and have an improved overall sense of emotional (and maybe even physical) well being.
Canceling and Rescheduling Appointments
I am a self-employed, fee-for-service therapist. I am not paid by an employer, I am paid by the service and can only bill your insurance company for reimbursement for your appointment if you attend the session. If you need to cancel or reschedule an appointment, 24 hours notice is required or you will be charged for that appointment. If the cancelation is under 24 hours notice, you will be charged $40. If you fail to attend the appointment without notice, you will be charged the full amount of the contracted fee as set by your insurance carrier. The fees will need to be paid before you can schedule a new appointment. This can be done by mailing a check, paying by credit card over the phone or using PayPal.
Professional Fees
My fee schedule is as follows:
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Initial Diagnostic Consult:
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$175
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Individual Therapy, 45 min:
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$125
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Individual Therapy, 60 min:
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$155
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Couples/Family Therapy:
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$175
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Reports, letters, completion of forms
not required by your insurance
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$40 per 30 min
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Phone consults with collaterals on your behalf
(ie, case managers, school personnel, etc.)
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$10 per 15 min
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Copy of Medical Record (including summary)
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$40 per 30 min
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Court or Deposition Services:
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$200 per hr
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Insurance Reimbursement
If you have a health insurance policy, it will usually provide some coverage for behavioral health treatment (typically, the contracted fee minus your co-payment/cost-share). A health insurance carrier (for example, Tufts) has over a 1000 different plans. There is no way for me to tell what plan you have and what it does and does not cover. It is your responsibility to know what is covered by your health plan. Procedure fees not covered by your plan, deductibles and co-payments are your responsibility. I reserve the right to use a third party to collect outstanding balances on fees not paid as well as legal proceeding in small claims court in an attempt to collect outstanding debt.
Professional Records
The laws and standards of my profession require I keep treatment records. You may submit a written request to examine or receive a copy of your records. In most instances, a written summary of your treatment will satisfy the various instances an individual may require a copy of his/her medical records. Fees will apply.