Counseling Practice Policies

Please review the following practice policies carefully. Your acknowledgment is required before beginning treatment.

Fees and Payment

Session fees are based on the type and duration of service. Current rates are discussed during your initial consultation.

Payment is due at the time of service. Accepted methods include credit/debit card, HSA/FSA, and other forms as arranged.

If your financial situation changes, please discuss with your therapist. Sliding scale fees may be available on a case-by-case basis.

You are responsible for co-pays, deductibles, or out-of-pocket costs not covered by your insurance plan.

Insurance and Billing

If using insurance, a mental health diagnosis is required for reimbursement. This diagnosis becomes part of your permanent medical record.

It is your responsibility to understand your coverage, including session limits, prior authorizations, and out-of-network benefits.

If your insurance claim is denied, you will be responsible for the full session fee. Superbills are available upon request.

How do you plan to pay for services? * Required

Insurance (in-network)Out-of-network (superbill provided)Self-pay / Private payEmployee Assistance Program (EAP)Sliding scale (if available)

Cancellation and No-Show Policy

Please provide at least 24 hours notice to cancel or reschedule an appointment.

Late cancellations (under 24 hours) or no-shows may be subject to a fee. This fee is not billable to insurance.

Repeated no-shows may result in a discussion about treatment commitment. Exceptions may be made for genuine emergencies.

I agree to the 24-hour cancellation policy and potential no-show fee. * Required

Yes No

Appointment Punctuality

Sessions begin and end at their scheduled times. If you arrive late, the session still ends as scheduled and the full fee applies.

If you are more than 15 minutes late without prior notice, the session may be considered a no-show.

Communication Between Sessions

Brief messages (scheduling, logistics) may be sent via the client portal, email, or text. Responses are during business hours.

Extended therapeutic conversations between sessions may be billed as additional services.

Email and text are not fully secure. Avoid sharing sensitive clinical information through these channels.

Your therapist is not available for crisis services. In an emergency, call 911 or the 988 Suicide & Crisis Lifeline.

Preferred contact for scheduling and non-urgent communication: * Required

Client portal messagesEmailText messagePhone call

Is it okay to leave a voicemail at the number on file? * Required

Yes No

Social Media and Online Presence

Your therapist will not accept friend or contact requests from clients on personal social media to protect confidentiality.

Your therapist will not search for you online unless you bring it into session. Please do not use social media to communicate.

Termination of Treatment

You may end therapy at any time. A termination session is encouraged so progress can be reviewed and referrals made.

Your therapist may initiate termination if treatment is no longer beneficial. Appropriate referrals will be provided.

If you do not attend sessions for 30 consecutive days without communication, your case may be closed.

Records and Documentation

Records are maintained per HIPAA and state law. You may request copies; a reasonable fee may apply for preparation.

Records are retained per your state licensing board requirements (typically 7 years after last service).

Acknowledgment

I understand the fees, payment, and insurance policies. * Required

Yes No

I understand the cancellation, no-show, and punctuality policies. * Required

Yes No

I understand communication, social media, and between-session policies. * Required

Yes No

I understand treatment termination and records retention policies. * Required

Yes No

Client Signature * Required

Signature

I acknowledge that I have read, understood, and agree to abide by the practice policies outlined in this document.

Counseling Practice Policies

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