Please review the policies listed below. Feel free to ask any questions you may have and then sign and date this agreement at the bottom. Thank you.

Confidentiality

Anything we speak about is confidential. I am both ethically and legally bound not to disclose any communication you share with me unless you give me permission to do so in writing.

The only exceptions to this are the following:

1. If I suspect that there may be a child under 18 who is being abused or     neglected, I must report this to Child Protective Services in NY or any other state.
2. If, in my judgment you are deemed to be an acute danger to your self or others, I may need to break confidentiality to assure your safety or the safety of others.
3. If I am court ordered to disclose information.

Audio or videotaping of our sessions is not permitted and may be cause for termination. Please be aware that I will not write reports or testify in court on your behalf.

Fees

My sessions are generally 50 minutes long, unless otherwise agreed upon. Payment is expected at the time of service or upon receipt of my bill at the end of each calendar month. Delinquent accounts will be subject to legal action if there is no effort to reconcile unpaid balances.

I am not an in-network provider for any insurance companies.  If you have out of network coverage, I will provide a separate statement that you can submit directly to your insurance company. It is a good idea to contact your insurance company to be apprised of what their out-of-network coverage is in advance of your first appointment.

Other services that may be charged for on an hourly basis include but are not limited to: letter writing, report writing, and telephone conversations or email correspondence with you or any authorized individual.

Cancellation Policy

Since I reserve time exclusively for you, I require a minimum of 24 hours cancellation. Failure to do so will result in being charged in full for the session.

I UNDERSTAND AND AGREE TO ABOVE TERMS.