Name: _________________________________________________

Philosophy & Financial Information

Philosophy

I view the counseling process as forming an alliance with you to explore the nature of your problem(s). I use a relationally based approach rooted in the understanding that all people are “broken” in some way. Specifically, I believe there is purpose in all behavior, and that purpose predominately resides in how we relate to one another both emotionally, physically and spiritually. Over time, we become stuck in patterned behavior ladened with negative self-concepts that interfere with our ability to have fulfilling relationships. This behavior fulfills some need, both positive and negative, and therefore is reinforced throughout our lives. It is desired that through the counseling process we will explore these needs and replace the negative ones with more functional positive ones, ultimately leading to a reconnecting to ones true self as well as more fulfilling relationships with others.

Fees and Payment

The basic fee for counseling will be $120 per 45 minute ($160/hr) office session but can vary depending on the service provided (fee schedule available upon request or can be found at https://allabouttrauma.com/wp-content/uploads/2019/05/HMCTI-Fee-Schedule-2019.pdf). If you are paying fee for service, all fees are due immediately before or after the session. If you are covered under insurance, all copays are due at the beginning or end of the session. The remaining fee will be billed to your insurance company and paid out at my contracted rate with them. Fees and/or copays are not applicable for Medicaid clients.

Cancellations

If you are unable to keep an appointment please notify my office immediately. If you miss an appointment with no notice (major emergencies exempted) you will be billed for the session.

Telephone Calls

If you need to speak with me between sessions, please call my office and I will return your call as soon as I can. I do not charge for brief conversations; however, any discussion that goes beyond 10 minutes will be billed on a pro-rated basis.

Termination

You may end treatment whenever you choose and you may seek a second opinion if you wish to do so. While you may end treatment at anytime, I request that you have at least one face to face termination session with me rather than terminating by phone or email.

Office: 2750 S. Wadsworth Blvd. – Suite D-103 Lakewood, CO 80227Remittance: P.O. Box 261329 Lakewood, CO 80226

Phone: 303/949/2726www.allabouttrauma.com

Collection of Fees

If in the event I am unable to collect said fees from yourself or your insurance provider using reasonable means, I may need to compromise confidentiality and provide basic demographic and session count data to a collection agency. By signing this document you are authorizing me to do this should the conditions warrant this action. I will attempt to notify you prior to the release of this information.

Authorization and Financial Commitment

I authorize counseling of the person(s) named below and agree to pay all fees and charges for such treatment. I agree to pay all charges for myself and members of my family promptly upon the rendering of services, unless other arrangements are agreed upon in writing. Charges shown by statements, if statements are rendered, are agreed to be correct and reasonable unless protested in writing within thirty days of statement date.

I attest that I have read this information form, that I understand the conditions as stated above, and that I consent to therapy, including evaluation, treatment and/or referral.

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Therapist Date

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Client Signature Date

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Parent or Guardian Signature Date

Office: 2750 S. Wadsworth Blvd. – Suite D-103 Lakewood, CO 80227Remittance: P.O. Box 261329 Lakewood, CO 80226

Phone: 303/949/2726www.allabouttrauma.com