The purpose of this Initial
Assessment Consultation is to determine your needs and to offer you treatment
recommendations. This session is for
assessment only. Treatment is offered
under a separate agreement.
Confidentiality: I am legally and ethically required to keep
our sessions confidential. As a result,
I will only release information to another professional or other interested
party with your written consent, except (1) when subpoenaed in certain legal
proceedings in which you give up your right to confidentiality, (2) in cases of
behavior that is actually or potentially a serious danger to yourself or
others, and (3) specifically, suspected child abuse or abuse of elders or
dependent adults. In some cases I would
be required to report to public agencies, and possibly to warn those who may be
at risk. I will tell you, if possible
and prudent, before I make such a report.
If you are unclear about anything in this paragraph, please ask me about
it as soon as possible.
Appointments: Time is reserved by agreement with you. If you need to cancel or change an
appointment time, please give 48 hours notice.
Cancellation without 48 hours notice will be charged to you at the
regular fee.
Length of sessions: Regular sessions are 45-50
minutes in length. One and 1/2 sessions
are one hour and 5-15 minutes, and double sessions are 90-100 minutes in
length. These times include the time
needed for business matters, such as making appointments and paying for the
session. Group psychotherapy is usually
90 minutes.
Fees: Payment is due at each
appointment. Payment for group psychotherapy is paid one month in advance. Please make checks payable to “Lee Blackwell,
Ph.D.” In order to use MasterCard or
Visa to pay your bill, you will need to fill out a separate form.
Insurance: Insurance will often cover part of the cost
of psychotherapy. If you filled out the
insurance page, I will provide you with a completed insurance form at the end
of each month, for you to sign and send to your insurer for processing. I do not belong to any insurance panels.
Collections: As stated above, payment for services
rendered is due and payable in full at the time the service is provided. If any balance remains 30 days following the
service date, I (we) agree to pay an additional charge of one and one-half per
cent (1½%) per month on the unpaid balance, except where a written agreement
exists to extend the payment period. In
the event the services of an attorney are required to pursue and/or collect any
past due sums, I (we) agree to pay reasonable attorney's fees and collection
costs.
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Patient signature Date
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Spouse/partner signature Date
