Professional Disclosure Statement
Professional Disclosure Statement
This document will provide you with information about the therapy services I
provide, some important policies concerning my practice, and hopefully answer
any questions you may have. It will also indicate your agreement to participate
in treatment and to adhere to the policies and procedures outlined below.
Description of Services
As outlined in the consent for services I will be providing outpatient therapy
services using a combination of cognitive behavioral, strengths based, trauma
informed, and internal family systems approaches. We will work together to
identify personalized, measurable goals and the steps we will take to reach them.
I accept Mainecare but at this time remain an out of network provider for private
insurance companies.
My scope of practice includes counseling to develop coping skills and improve
mental health. My practice does not offer case management services,
psychological testing or evaluations, disability claims evaluations, medication
management, custody or forensic evaluations, substance abuse treatment, court
ordered treatment, or accept attorney, DHHS, or probation based referrals.
Costs for Patients with Private Insurance
My standard rate for the initial appointment is $150 and $120 for each
appointment following the initial visit. Payment is due at the beginning of each
session. I ask that a credit/debit or HSA card be kept on file, however you are
more than welcome to use an alternative method of payment when you arrive.
My standard hourly rate would also apply in the event that I am subpoenaed to
court, whether I am called to testify or not, mainly because time away from the
office is time that I am not able to meet with clients. There are no partial charges
for sessions. If you happen to be late to a session the full session rate would still
apply.
If it is your intention to seek reimbursement from your insurance company for
services, it will be your responsibility to verify the following information with
your insurance company:
● Is there a deductible that must be met before receiving out of network
mental health services?
● Once I meet my deductible, what are the benefits for out of network mental
health services?
● Are there limits to my reimbursement such as a maximum amount per
session or a limit to the number of sessions I can receive?
● Are appointments through telehealth covered under my policy?
Cancellation Policy
I respectfully request 24 hours notice if an appointment needs to be canceled or
rescheduled. This request is made so that I am able to utilize the available time
slot for another client. You will be responsible for all session fees for
appointments not canceled 24 hours or more in advance. I understand that
emergencies occur and will address these situations on an individual basis.
A pattern of repeated cancellations may result in the loss of a standing
appointment time, or cause for discharge from services.
In the event of inclement weather I will contact you if my office closes. If you are
ever uncomfortable with driving conditions please know that a telehealth session
is always an option.
Availability
My current office hours are Tuesdays, Wednesdays, & Thursdays 9-4:30, and Fridays
8-12. If you leave a message please know I will do my best to return your call
within one business day. Given my limited availability I am not able to provide
emergency services. If such a need arises please access your local emergency
room, call 911, or utilize the 24 hour emergency helpline by calling 888-568-1112.