Tanya K. Hull, Lpc, Rpt/S

FAMILY THERAPEUTICS, INC

TANYA K. HULL, LPC, RPT/S

Licensed Professional Counselor

Registered Play Therapist/Supervisor

10353B Democracy Lane, Fairfax, VA 22030

703-405-4171 Fax# 540-707-9212

Counseling Agreement & Consent to Treatment

THERAPIST-CLIENT SERVICE AGREEMENT:Welcome to my practice and thank you for choosing Family Therapeutics for your counseling needs. This document contains important information about my professional services and business policies.

COUNSELING SERVICES:Therapy sessions can vary from weekly to monthly check in meetings. Typically getting started meetings are held weekly. Initial 2-4 sessions will be an evaluation of needs, possible recommendations, and if the therapeutic relationship is a good fit for both parties involved. If needed appropriate referrals can be made during the initial evaluation period. Treatment goals will be created with realistic modes of therapy to address client concerns. When children are part of the therapy process, all children need to be supervised by an adult while in the building at all times to insure their safety.

PATIENT RESPONSIBILITIES

Provide accurate information about past illness, hospitalizations, medications, family history, life-style habits and behaviors.
Clearly understand the nature of our work together and ask for clarification when needed.
Regular attendance to scheduled appointments and timely notice of rescheduling appointments.
Follow through with treatment assignments and tasks.
Payment of services on the day they are received.

PATIENT RIGHTS

A description of the recommended treatment including risks and benefits.
The right to confidentiality under the laws of Virginia and HIPAA federal privacy practices which have been provided.

CONFIDENTIALITY: The information provided will be treated confidentially and won’t be made available without your written consent. The instances in which confidential information can or must be released without consent is stated below:

If you pose a serious danger to yourself or others.
If neglect or abuse of a child or adult is suspected.
If a court issues a subpoena concerning your records.
Insurance requires a medical review of treatment services.

In cases in which information must be released without consent, every attempt will be made to notify you beforehand. Please review HIPAA regulations that have been provided for you.

APPOINTMENTS: Therapy sessions are 50-55 minute sessions. If you need to cancel or reschedule appointments you need to give 24 hour advanced notice to avoid a missed session fee of $75. Insurance companies do not provide reimbursement for missed/cancelled sessions. If you arrive late to your appointment, your session will still end on time, or may need to be rescheduled. Two consecutive missed sessions or a frequent pattern of missed sessions may result in termination of therapy services.

COURT FEES: Request for expert/witness testimony will be billed at $1,500 per day. Fees cover time during court date, travel, and preparing for testimony. If case is resolved outside of court in the 24 hours prior to the court date, the full fee will still apply. This fee is to honor the time and preparation made for testimony.

CONTACTING ME:I am typically available to talk with my current patients during regular office hours of Monday through Thursday. All calls are responded to within 24-48 hours time for non-urgent matters Monday through Thursday. I am available by phone and email only, texting and social media are not an acceptable form of communication. I will return calls outside of office hours only in cases of life threatening emergencies. Please note, to insure your right to privacy I don’t use emails or texts to discuss clinical issues and these discussions are to be scheduled for in session. Email is only used for scheduling and administrative issues and can be included in patient medical records. Family Therapeutics, Inc. isn’t a 24 hour emergency practice. If you can’t safely wait a return phone call please call 911 or go to your local emergency room.

TERMINATION:Therapy usually ends after mutual agreement about readiness and goal completion with maximum benefit. You may of course terminate at any time. If you cancel or miss scheduled appointments and do not contact me for more than 30 days, it is understood that you have terminated treatment, and your case will be closed. Frequently missed sessions may also result in termination of services. Once treatment is terminated, the therapist has no further obligation to the client. If you have completed therapy and wish to resume at any point in the future, I will make every effort to accommodate you scheduling needs.

Patient Information:

Name:D.O.BSS#

Address:

Parent/Guardian:

Home#Work#Cell#

Email address:

Medications:

School:Grade Age

Recent Diagnosis:

CONSENT TO THERAPY: My signature below indicates that I have read the above agreement and notice of privacy practices. I am in agreement and understanding of this consent for therapy with Family Therapeutics, Inc. and Tanya K. Hull, LPC, RPT/S.

Signature of Patient/ClientDate