Welcome to Accepted Therapy Services. This document contains important
information about our professional services and business policies. Although
these documents are long and sometimes complex, it is very important that
you understand them. When you sign this document, it will also represent an
agreement between us. If you have any questions, we can discuss them prior
to you signing the document; however, no therapy services will be provided
until a signed copy of this document has been received.
The first 2-4 sessions will involve establishing a relationship, developing
treatment goals, and creating an initial treatment plan. During this time, I
will have an opportunity to get to know my therapist and to make my own
assessment about whether I feel comfortable working with them. If I have
questions about the procedures that are outlined in this document, I will
discuss them whenever they arise. If my doubts persist, I will ask my
therapist to help me set up a meeting with another mental health
professional for a second opinion.
Psychotherapy requires a very active effort on my part. In order to be most
successful, I may have to work on things that are discussed outside of
sessions. This may be through homework which, if assigned, will be specific
to the work that I am doing in sessions. Any homework assignment that is
given to me, will be tailored to my experiences and current level of coping
The benefits of therapy can include:
One of the benefits of therapy is having someone that I can talk
to and who is on my side. Sometimes, my therapist may challenge
push me to improve in a certain area. I understand that this
or challenging is for my benefit so that I may change the areas
are preventing me from having a life worth living. Sometimes,
someone to help me carry my burdens is helpful.
Other benefits of therapy may include:
The risks of therapy can include:
Sessions are 50-60 minutes in duration on an agreed upon day and
as needed. I recognize that the time scheduled for my session is set
aside for me. I am responsible for coming to my session on time. I
understand that if I am late to my session, my appointment will
end at the same time it would have ended if I would’ve been on time.
therapist has the right to cancel the appointment if I am more than
minutes late to my session.
If I need to cancel or reschedule a session, I agree to provide my
therapist with 24 hours’ notice. If I miss a session without
or cancel with less than 24-hour notice, my therapist may collect a
in the amount of $75 [unless it is agreed upon in writing that I was
unable to attend due to circumstances beyond my control]. It is
important to note that insurance companies do not provide
for cancelled sessions; thus, I will be responsible for the portion
the fee as described above.
I understand that there may be instance where telehealth services
provided through TheraNest Telehealth includes any video or over the
phone sessions. I understand that the therapy I will be receiving
not be the same as a direct client/health care provider visit due to
fact that I will not be in the same room as my provider. I
that a telehealth consultation has potential benefits including
access to care and the convenience of meeting from a location of my
I accept responsibility for ensuring that my session in private when
using telehealth services through TheraNest. The location that I
for my session should be in a quiet, private room where the session
not be over heard. If I choose to have a telehealth therapy session
public place, Accepted Therapy Services or my therapist is not
responsible for any information that may be overheard by others. I
understand that my therapist will always be in a confidential
when telehealth services are being provided.
I understand there are potential risks to this technology, including
interruptions, unauthorized access, and technical difficulties. I
understand that my therapist or I can discontinue the telehealth
consult/visit if it is felt that the videoconferencing connections
not adequate for the situation.
To maintain confidentiality, I will not share my account access
information with anyone unauthorized to attend the appointment.
Payment can be made by credit card, check, cash, CashApp ($AcceptedTherapy), or Venmo (@AcceptedTherapy).There will be a convenience fee of $2.00 for each invoice that is paid for with a credit or debit card. To avoid this fee, I can pay with cash, check (made out to Accepted Therapy Services) CashApp ($AcceptedTherapy) or Venmo (@AcceptedTherapy).
Any checks returned to Accepted Therapy Services are subjected to an additional fee of up to $50.00 to cover the bank fee that is incurred. If I refuse to pay my debt, of any fees that are owed to Accepted Therapy Services, I understand that Accepted Therapy Services reserves the right to use an attorney or collection agency to secure payment.
In addition to fees accrued during sessions, I understand that a prorated fee will be charged for other professional services that I may require such as report writing, telephone conversations that last longer than 15 minutes, meetings or consultations which I have requested my therapist to attend, or the time required to perform any other service which I may request of my therapist.
The standard fee for the initial intake and each subsequent
session is $150.00 per session. In the event that I choose to
participate in EMDR therapy, it may be recommended that the
sessions will be 90 minutes long with a fee of $225.00. I am
responsible for paying at the time of my session unless prior
arrangements have been made in writing.
If I am more than 10 minutes late to a session, miss a session
without canceling, or cancel with less than 24-hour notice, a fee in
the amount of $75 [unless it is agreed upon in writing that I was
unable to attend due to circumstances beyond my control] will be
charged. It is important to note that insurance companies do not
provide reimbursement for cancelled sessions; thus, I will be
responsible for the portion of the fee as described above.
My therapist has a library of books that is available to me if I
wish to read on various topics that may be discussed during therapy.
Books that are loaned to me should be returned within a reasonable
time frame (two month maximum). If the book is not returned or is
damaged upon return a fee of $25 plus the cover cost of the book,
will be charged to my card on file.
If I anticipate becoming involved in a court case, I will
discuss this fully with my therapist before I waive my right to
confidentiality. If my case requires my therapist’s
participation, I will be expected to pay for the professional
time required even if another party compels my therapist to
The fees for court involvement are:
In order for us to set realistic treatment goals and priorities, it is
important to evaluate what resources I have available to pay for my
treatment. If I have a health insurance policy, it will usually provide some
coverage for mental health treatment. With my permission, my therapist will
assist me to the extent possible in filing claims if she is an in-network
provider for my insurance. I understand that I am responsible for knowing my
coverage (including co-insurance and co-pays) and for letting Accepted
Therapy Service know if/when my coverage changes. If my therapist is not a
participating provider for my insurance plan, I understand that she will
supply me with a receipt of payment or superbill, upon request, for services
which I can submit to my insurance company for reimbursement. Please note
that not all insurance companies reimburse for out-of-network providers. If
I prefer to use a participating provider, my therapist will refer me to
another mental health professional.
I am aware that most insurance companies require my therapist to provide
them with a clinical diagnosis/diagnoses. (Diagnoses are technical terms
that describe the nature of my problems and whether they are short-term or
long-term problems. All diagnoses come from a book entitled the Diagnostic
and Statistical Manuel 5th Edition or DSM-5. There is a copy in my
therapist’s office that I can look at if I would like to learn more about my
diagnosis, if applicable.). Sometimes my therapist may have to provide
additional clinical information such as treatment plans or summaries, or
copies of the entire record (in rare cases). This information will become
part of the insurance company files and will probably be stored in a
computer. Though all insurance companies claim to keep such information
confidential, I recognize that my therapist does not have control over what
the insurance company does with it once it is in their hands. In some cases,
they may share the information with a national medical information databank.
If I want a copy of any report my therapist submits, I can request it at any
time. By signing this agreement, you agree that I can provide requested
information to your carrier if you plan to pay with insurance.
In addition, if I plan to use my insurance, authorization from the insurance
company may be required before they will cover therapy fees. If I do obtain
authorization and it is required, I may be responsible for full payment of
any fees accrued. Many policies leave a percentage of the fee (which is
called co-insurance) or a flat dollar amount (referred to as a co-payment)
to be covered by me (the client). Either amount is to be paid at the time of
the visit via any of the accepted payment methods. In addition, some
insurance companies also have a deductible, which is an out-of-pocket
amount, that must be paid by me (the client) before the insurance company is
willing to begin paying any amount for services. This will typically mean
that I will be responsible to pay for initial sessions with my therapist
until my deductible has been met. The deductible amount may also need to be
met at the start of each calendar year. Once we have all of the information
about your insurance coverage, we will discuss what we can reasonably expect
to accomplish with the benefits that are available and what will happen if
coverage ends before I feel ready to end my sessions. I understand that I
always have the right to pay for my therapy services out-of-pocket if I wish
to avoid any of the problems described above.
I understand that my therapist is required to keep appropriate records of
the therapy services that are provided. My records are maintained in a
secure electronic medical record (EMR) through TheraNest. The records kept
in my EMR may include information such as: dates of services, reasons for
seeking services, goals for treatment, progress in treatment, prognosis,
diagnosis, topics discussed in sessions, and billing records.
I have access to my records in most instances, upon request, unless there
are unusual circumstances that may result in emotional distress or harm me
if were to review my records. Because these are professional records, there
is a chance that they may be misinterpreted and/or upsetting to untrained
readers. For this reason, it is recommended that if I wish to review my
records, I initially review them with my therapist or have them forwarded to
another mental health professional to discuss the contents. If my therapist
refuses my request for access to my records, I have a right to have her
decision reviewed by another mental health professional, which will be
discussed with me upon my request. I also have the right to request that a
copy of my file be made available to any other health care provider at my
The therapeutic relationship is a confidential relationship where no
information will be disclosed about me, or the fact that I am receiving
services from Accepted Therapy Services, without my written consent.
Healthcare providers are legally allowed to use or disclose records or
information for treatment, payment, and healthcare operations and purposes.
I understand that my therapist does not routinely disclose information in
such circumstances, so she will require my permission in advance, either
through my consent at the onset of the therapeutic relationship or through
my written authorization at any time a need for disclosure arises. I may
revoke my permission, in writing, at any time, by contacting Accepted
As mentioned above, the information that I share with my
therapist is confidential unless a written consent is received.
There are; however, a few limits to confidentiality (or
instances in which my therapist may disclose confidential
information without my consent) that I should be aware of before
beginning services with Accepted Therapy Services.
The staff of Accepted Therapy Services meets weekly to discuss cases
including but not limited to progress in treatment, barriers to
progress, and/or other concerns that may be noted by my therapist.
Occasionally, my therapist may need to consult with other
professionals in their areas of expertise in order to provide the
best treatment for me. I understand that information about me may be
shared in this context without using my name or any other protected
health information (PHI).
While privacy in therapy is crucial to successful progress, parental
involvement can also be essential. I understand that it is the policy of
Accepted Therapy Services not to provide treatment to a child under age
unless the child agrees that information can be shared when necessary
For children 14 and older, an agreement between the client and the
allowing the therapist to share general information about treatment
and attendance, as well as a treatment summary upon completion of
All other communication will require the child’s agreement, unless there
a safety concern (see above section on limits to confidentiality).
Therapy Services will make every effort to notify the child of any
to disclose information ahead of time and make every effort to handle
objections that are raised.
I understand that Accepted Therapy Services is NOT an Emergency
and in the event of an emergency, I will use a phone to call 911. This
includes suicidal ideations, homicidal ideations, and other mental
health concerns I may have. Though my provider and I may be in direct
contact through the Accepted Therapy Services or TheraNest EMR, I
understand that my therapist does not provide any medical or healthcare
services or advice including, but not limited to, emergency or urgent
I understand that my therapist is not often immediately available by
telephone. My therapist may not always answer their phone due to being
in a session with another client or out of the office. At these times, I
may leave a message on the confidential voicemail of Accepted Therapy
Services and my call will be returned as soon as possible. I understand
that it may take up to two business days for calls to be returned. If,
for any number of unseen reasons, I do not hear from my therapist or
they is unable to reach me, and I feel that I cannot wait for a return
call or am unable to keep myself safe, I will 1) call 911 or 2) go to my
local hospital emergency room.
If I am unhappy with what is happening in therapy, I will talk with
Nikki Dear, LCSW, or my therapist to provide her with an opportunity
to respond to my concerns. Such comments will be taken seriously and
handled with care and respect. I may also request that I be referred
to another therapist and am free to end therapy at any time.
I have the right to considerate, safe and respectful care, without
discrimination as to race, ethnicity, color, gender, sexual
orientation, age, religion, national origin, or source of payment.
I have the right to ask questions about any aspects of therapy and
about my therapist’s specific training and experience.
I have the right to expect that the relationship will be professional
and will not include social or sexual relationships with clients or
with former clients. If we see each other accidentally outside of
the therapy office, I understand that my therapist will not
acknowledge me first. My right to privacy and confidentiality
extends to public settings and my therapist does not wish to
jeopardize my privacy. However, if I acknowledge my therapist first,
she may speak briefly with me, but will not engage in any lengthy
discussions in public or outside of the therapy office.
I understand that the service provided through Accepted Therapy
Services is not intended for crisis situations and urgent needs. In
a crisis situation, I agree to call 911 or local emergency services,
or visit the nearest emergency room. Information shared with my
therapist is confidential except in the following circumstances: If
I present as a danger to myself or others, mandated reporting of
abuse of children or elders, or if I sign a release of information.
That I have been given ample opportunity to ask questions and that
any questions have been answered to my satisfaction.
That I have read or had this form read and/or had this form
explained to me.