KIMBERLY KLINE, MA, LPC

Licensed Professional Counselor#14177

833 E Arapaho Rd #101

Richardson, TX 75081

Ph.214-543-5977

INITIAL SESSION CONTRACT

I ______, am attending counseling sessions voluntarily and understand that Kimberly Kline, M.A., L.P.C. is available 24 hours a day to me and she has given me permission to go to the nearest emergency room if I feel I am in immediate danger and will explain to me the situations in which I may need to call the suicide hotline.

_____ I understand that Kimberly may terminate our therapeutic relationship if I fail to appear for three sessions and that I will be given notice of termination. I understand that Kimberly may terminate our relationship if I fail to comply with recommendations regarding my personal safety. Kimberly will refer me to other sources of therapy at that time.

Kimberly has my permission to seek peer supervision in an anonymous way in her peer supervision group. I understand that I may call the Texas Board of Licensed Professional Counselors at Complaints Management and Investigation Section, PO Box 141369 Austin, TX.78714-1369, in regards to any complaints I may have regarding Kimberly and/or my counseling experience with her.

____I understand that if I do not give 24 hours notice to Kimberly prior to canceling my appointment, on more than one occasion, I will be charged for the missed appointment. I understand that Kimberly charges $180 for an initial session and $90 for any following sessions. Sessions are to be 45 to 50 minutes in length. I agree to pay a $15 fee for administrative services at each session for 10 sessions. ($150). This is not a co-pay or co-insurance fee but an office/administration fee which is not a covered expense.

I understand that if I am being asked to help initiate insurance coverage that I may be asked to help recover any fees that are not reimbursed as were represented to Kimberly by myself.

I further understand that Kimberly may not receive any gifts of any value from me and that she may not engage in any relationships with me, other than a therapist and client one. It is my understanding that Kimberly will not engage in any routine touching of my person, (with the exception of biofeedback therapy or auriculotherapy). I am aware that the goal of counseling is to assist me in feeling better and understanding this I agree to enter this relationship in good faith.

Signature ______

Parent/guardian if pt is a minor child______

DATE:______

Pt. NAME:______

Parent Name if minor child ______

Parent DOB: ______

Patient SS#______

Patient DOB: ______

ADDRESS: ______

______

HOME PHONE:______

WORK #:______

Employer ______

Spouse’s Name: ______

Spouse Ph # ______

Employer ______

Credit card info for no shows or payments over $40

Visa/MC ______exp ______

Signature for payment approval______

Billing address is same as home address? ______

EMERGENCY CONTACT: _____/ #______

Relationship ______

Address: ______

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