Patient Psychological Services Contract

Appointment Scheduling and Cancellation Policies

Appointments are scheduled as 50-minute or 90-minute sessions. Sessions are scheduled once a week at the same time and day if possible unless we agree otherwise. Consistency in attendance is important for a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify me at least 24 hours in advance of your appointment. If you do not provide me with at least 24-hour notice, you will be responsible for full fee payment for the missed session. Please understand that your insurance company will not pay for missed or cancelled sessions.

Professional fees

The fee for service is $200 per 50 minute, therapy session.

For therapy bundle discounts, please refer to www.DoctorLeslieDavis.com for pricing options.

Billing and Payment

Payments will take place when the session occurs. I accept cash, check, Venmo, Zelle, and Paypal options. Please inform me if you wish to use your PPO health insurance to pay for services. The amount of reimbursement, co-payments and deductible depends on your specific insurance plan. Be aware that insurance plans generally limit coverage to certain diagnosable mental conditions. You are responsible for contacting your insurance, verifying and understanding the limits of your insurance coverage.

All other professional services will be prorated and billed at $200 per 50 minutes. Other services include report writing, phone conversations more than 15 minutes, attendance to meetings with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other services 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. These fees include preparation and attendance at any legal proceedings.

Contacting Me

I can be reached by phone call or e-mail. You may contact me between sessions however, I will attempt to keep those contacts brief due to my belief that important issues are better addressed within regularly scheduled sessions.

Non-urgent phone calls and e-mails are returned Monday through Thursday, 8 AM – 6 PM. I will attempt to return calls and e-mails within 24 hours. If your call is urgent, please indicate so in your message. I do accept text messages, however please be mindful that I am usually in sessions during work hours.

In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance.

Professional Records

The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of records unless I believe that viewing them would be emotionally damaging, in which case I will gladly review them with you or send them to a health professional of your choice. I recommend that you review them in my presence so we can discuss the contents. Clients will be charged a pro-rated fee for any time spent in preparing information requested. I require a 10-day notice to prepare any records to be requested or reviewed.

Couples Therapy

While I am currently  training in the Gottman Method Couples Therapy, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. The Gottman Institute or its agents have no responsibility for the services you receive.

Confidentiality

All communications between you and me, as your therapist, are strictly confidential unless you provide written permission to release information about your treatment. There are however exceptions to confidentiality. I am legally obligated to report the following:

1.           Knowledge of or suspected child abuse, dependent adult or elder abuse.
2.           If a client presents a danger to self or serious danger or physical violence to another person.  

In case of danger to self, efforts may include cooperation of the client to ensure their safety, contacting family members or others to help provide protection, or hospitalization for the client if necessary.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings a judge may order my testimony if they determine that the issues demand it. If this occurs, I will make every effort to fully discuss it with you before taking any action.

I occasionally engage in case consultation with other professionals. During consult, I make efforts to avoid disclosing the identity of clients. The consult is also legally bound to keep information confidential.

If you participate in couples or family therapy, I utilize a “no-secrets” policy when conducting family or marital/couples therapy. Please feel free to ask me how it may apply to you.

Communications between therapists and clients who are minors (under the age of 18) are confidential. However, parents/guardians who provide authorization for their child’s treatment are often involved in their treatment. Occasionally, I may discuss the treatment progress of a minor with the parent/guardian. If you have any questions or concerns on this topic, I encourage you discuss them with me. 

Termination of Therapy

The length of your treatment depends on the specifics of your treatment plan and the progress you achieve. Termination is typically planned, in collaboration with me as your therapist. I will discuss a plan for termination with you as you approach the completion of your treatment goals.

You may discontinue therapy at any time. If you or I as your therapist determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. This may include, referral, changing your treatment plan, or terminating your therapy.

Your signature below indicates that you have read the agreement for services carefully, understand its contents and agreed to abide by its terms during our professional relationship. Please address any questions or concerns that you have about this information before you sign.