Client Consent & Payment Agreement for Natalie Smith, Psy.D.
WILL THERAPY HELP?
The most common benefits of therapy include improvements in self-awareness, self-esteem, and self-confidence, as well as in hope, feeling understood, relationships with other people, emotional expressiveness, and taking an active and responsible role in one’s life. There can also be risks associated with being in psychotherapy. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. You may already be in the midst of stressful changes or challenges in your life. My role is to help you to cope with these challenges in ways that serve your well-being and that of the people in your life. Periods of change are often stressful, and they are sometimes turbulent. You may experience a range of emotions and changes in your relationship with yourself and others (including me). It is extremely rare for people to be harmed by their experience in therapy.
WHAT WILL PSYCHOTHERAPY COST?
***PAYMENT IS REQUIRED AT THE TIME SERVICES IS RENDERED ***
Natalie Smith, Psy.D. accepts payments in cash, check, PayPal, Zelle, Venmo, or any other bank direct deposit. Credit cards is used as a last resort.
Professional Fees: The session fee for individual is $180.00 for a clinical hour. In the event that sessions extend beyond the clinical hour, the fee will be increased. For couples the fee is $300.00 for 90 minutes. Hypnosis sessions are $225.00 for the clinical hour.
Other services that will be charged: reading and responding to extensive emails, report writing, telephone conversations lasting 10 minutes or longer, consulting with other professionals where you have authorized contact, preparation of records or treatment summaries, and the time spent performing any other service you may request of me; these fees will be pro-rated by the hour.
If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $250.00 per hour (with a minimum engagement of three (3) hours) for preparation for and attendance at any legal proceeding.
Cancelled/Missed Appointments Fees: Once an appointment is scheduled, or you cancel the day of the session (as of midnight), you will be expected to pay the full session amount. This includes being sick. The only time you will not be charge is if FFCPS is closed due to inclement weather. All sessions that are cancelled less than 24 hours prior to the scheduled session time will be billed a $100 fee. Insurance companies do not reimburse for cancelled session fees. You understand that you will be fully responsible for these fees. Please feel free to discuss any questions and concerns regarding this policy.
Returned Check Fee: A $35.00 fee will be assessed for each returned check.
Transfer of Records: You understand that you will be charged a full session’s fee for the time it takes to prepare records. This payment is due in full prior to the copying and forwarding of records.
Payments: By signing this form, you are confirming that you understand that it is your responsibility for full payment of fees. In the event that you assume I’m in-network, and your insurance fails to pay you a percentage, then you are responsible for full payment of session fees.
You are confirming that you understand it is your responsibility to: pay, at the time services are rendered, the agreed upon session fee, co-pay, co-insurance, deductible, or any other fees relating to services rendered, provide me with a current mailing address, email address, and phone numbers, as well as notification when there are any changes to this information, confirm with your insurance company that Natalie Smith, Psy.D. is a participating provider under your specific insurance plan, provide me with appropriate and current insurance information and updates to ensure efficient billing and payment.
Collection Fees: In circumstances involving unusual financial hardship, I may be willing to negotiate a payment installment plan. If your account has remained unpaid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve submitting the account to a collection agency or filing a claim in small claims court, either of which will require that otherwise confidential information be disclosed for the purposes of collecting payment.
Client Discharge: In the event of failure to pay for services rendered, you understand that you may be discharged from the services of Natalie Smith, Psy.D. until such time as your account is fully paid. Additionally, you understand that you may be referred to a collections agency for non-payment of fees due for services rendered by Natalie Smith, Psy.D. You understand that you will be responsible for all collection fees, all agency and attorney fees and costs associated with the collection process (such as court costs), and that these fees and costs will be added to your account balance. You understand that you will be responsible for paying the entire amount of your balance due in addition to any collection fees. Further, you understand that your personal health information will be revealed in these efforts to collect payment of monies owed.
I am often not immediately available by telephone; specifically, I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by a confidential voice mail that I monitor frequently. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If I am unavailable for an extended time, I will provide you with the name of a colleague to contact during my scheduled absence.
- In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission. However, State law dictates some limits on your privacy of which you should be aware. Exceptions to your privacy include the following:
These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. Additionally, when I am away from my office I will have a trusted colleague “cover” for me. That person will be available for emergencies and thus may need to know about my clients.
- Your typed signature below indicates that: