Stacy N. Broun, Ph.D.

Clinical Psychologist

3609 Cedar Springs Rd.

Dallas, TX. 75219

(214) 521-6972

Fee and Payment Agreement and Informed Consent Notice

For Psychotherapy Services

Client’ Name and Address:Provider’s Name;

______

Welcome to the psychotherapy practice of Dr. Stacy N. Broun. Our goal is to provide you with quality mental health care. Your informed participation, and your understanding of payment arrangements are essential to our effort to help you, as well as to your effort to benefit from our time together. The following statements describe our agreement regarding the services that we will provide you and the fees that our office charges for our time and services.

Services

You and your therapist will meet ______times per ______(week/month) for a session that will last between 45 and 50 minutes (Other ______). The scheduled time is your time to use the to your best advantage. At your discretion and with the agreement of your therapist, I will meet with you alone, or with you and your spouse or other party, together. If you are unable to attend you may cancel if you give our office at least 24 hours’ notice. If you must be late or you are unable to cancel in time, the scheduled time will still be your time and it will be your responsibility to pay for that session; your insurance carrier will not pay for missed sessions. This agreement for services will remain effective until ended by agreement between you and your therapist. If a minor client seeks treatment with Dr. Broun, both parents must provide signed agreements with Dr. Broun’s office giving Dr. Broun permission to treat the minor. Whether parents remain married, treatment of minor children requires the cooperation and agreement from both parents.

Payment

Our customary fee for counseling and psychotherapy is $______per visit. That fee will be charged for each visit and is expected to be paid in full at the time of your session. Whether you are seen alone, or with other family members, your fee will be the same for each session. Furthermore, we do not accept any direct insurance reimbursement. If needed, please let us know and on your monthly statement, all the information that you need to request out-of-network reimbursement will be included.

Other Fees

After hours telephone calls may be accepted if you are in crisis. There is no charge for a phone call that lasts ten minutes or less. For telephone consultations that require more than ten minutes, our office charges ______for each fifteen-minute increment or any part of a fifteen-minute increment. Both of these fees are due and payable when they are incurred, but must be paid by the time of your next scheduled visit; insurance does not ordinarily pay for telephone consultations. There may be times when you want your therapist to read documents that will help with understanding you. If reading such documents requires extensive time, your counselor will bill you for that time, fees that your insurance company will not pay.

Confidentiality

All information disclosed within sessions, including that of minors is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. Disclosure may be required in the following circumstances:

  1. When there is a reasonable suspicion of child abuse or abuse to a dependent or elder adult.
  2. When the client communicates a threat of bodily injury to others.
  3. When the client is suicidal.
  4. Physical injury due to violence.
  5. When disclosure is required pursuant to a legal proceeding.

I receive regular professional consultation. In such cases, neither your name nor any identifyinginformation about you is revealed.

Emergency Procedures

If you need to contact me between sessions, please leave a message with my answering service by dialing 214-521-6972 and your call will be returned. If an emergency situation arises, inform the telephone service that your call is an emergency. The service will make every effort to reach me directly. Please do this for true emergencies only.

When I am out of town or otherwise unavailable, a qualified professional will cover for me. You will find their telephone number by checking with our answering service (214-521-6972).

I HAVE READ AND AGREE WITH THESE POLICIES.

Client: ______

Signature: ______

Dated: ______

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