This Page Includes:

Disclosure Statement Sample Language:

Relating to Fees

Relating to Maintenance of Minimal Records

Letter to Client who has Disappeared from Sessions

Sample Letter

Sample Language Relating to Fees

Fees and Scheduling

Your costs for therapy will be specified at the beginning of treatment. Occasionally I find it necessary to increase my fee due to inflation. If this occurs during your treatment, you will be given one month notice prior to the increase. The fee is set on a fifty minute session basis. I prefer to be paid weekly unless special arrangements have been made. If you have any questions regarding payments, I encourage you to ask.

If you are intending to use your insurance mental health benefits to pay for all or part of your treatment costs, you should be aware that my contract is with you, not your insurance company. Although I am happy to assist you by billing your insurance company, you are financially responsible for all fees.

You should also be aware that there are certain treatment circumstances for which insurance companies generally do not provide payment: i.e., missed but scheduled sessions, telephone consultations, etc.

PLEASE NOTE: When we make an appointment, I am committing to hold that time for you. If you are unable to keep your scheduled appointment for any reason, please give me at least 24 hours advance notice or you will be charged the full amount for the time reserved for you. If I miss a scheduled appointment without notifying you, I will make up the session with you, without charge.

Sample Language Relating to Maintaining Minimal Records

I have read and understand the Disclosure Statement of Jennifer Melfi, M.D., have had an opportunity to ask questions about it, and have been given a copy for my records. I have also received a copy of the state brochure for counseling and hypnotherapy clients.

I have also made a request of Dr. Melfi to not keep clinical notes documenting the content or focus of our sessions as stipulated in WAC 246-810-035(2), and understand that she has agreed to this request. _____________________ (initials of client)

I agree to begin therapy with Jennifer Melfi, M.D. for the agreed upon fee of $  ___       per fifty minute session.

_________________ (client’s signature)__________ (date)

_________________ (counselor’s signature) ______ (date)

Sample Letter (to a client who has stopped coming):

Dear Tony,

I want to acknowledge that we have not been meeting for some time now and to let you know that I think of you and wonder how you are doing. My recollection is that we never discussed your ending or a break from therapy, in fact I believe our last contact was to cancel a scheduled appointment. But I want to say that if you have decided to either end or take a break, I honor this decision.

I would like you to know that I enjoyed our work together and will hold as a trust, your decision to risk sharing aspects of your life with me. Please know that you are welcome to return at any time if you feel it would be helpful to you. I wish you well.

Very Sincerely,