The Therapist’s Responsibilities Include:

1. Creating a sound treatment plan responsive to the client’s needs.
2. Following professional and HIPAA policies regarding confidentiality.
3. Being available to the client at the client’s scheduled time.
4. Not allowing interruptions during the client’s appointment unless there is an emergency situation.

The Client’s Responsibilities Include:

1. Making an effort to talk openly with the therapist.
2. Participating in and following through on mutually established treatment goals.
3. Informing the therapist of any changes in insurance coverage, and being responsible to pay for session not covered by insurance.
4. Making co-payments (or payments) at the time of each visit.
5. Coming on time to all scheduled appointments or canceling 24 hours ahead of time so that the therapist can make the best use of the available time.
6. Understanding that excessive no-shows or cancellations, even if paid, may result in decision to close your case with the therapist, with a referral elsewhere if required.
7. Providing credit card information to be kept on file, including expiration date and CVR code. Signing this form is an acknowledgement that you agree to be charged on this card in the event of a late cancellation or no-show. No-show fee is $35. Two consecutive no-shows/late cancellations will result in a $65 fee.

Client Signature:
Date:

**All fields must be completed in order to successfully submit this form