Client Informed Consent

lient Informed Consent

Please read through the entire document.
Welcome! I am very excited to know you and am looking forward to our work together. The purpose of this form is to explain the policies of my practice and to inform you of the rules of confidentiality that I am bound to.    After you've read the entire document, then sign and date at the bottom. The signature page is required before I am able to speak with you for your first session, so please remit this form at your earliest convenience.

Talk to you very soon!
Paige

Client Agreement-Informed Consent

Fees & Payments:
• 24 BUSINESS HOURS' notice is required to cancel an appointment without incurring charge.
• The full fee will be incurred for missed sessions. Please cancel with 24 hours notice to avoid these fees.
'He who forgets a session, pays for the session."
• Sessions: All sessions are 65 minutes and are held by PHONE. Weekly appointments are billed at a lower rate than bi-weekly or monthly appointments to help clients afford the weekly appointments they may need. (Click HERE for information about fees).
• Overtime: Often, you may feel that you're work isn't finished at the 65 minute mark. If we need to go into overtime, a fee of $25 is charged for every 15 minute increment.
• Emergency sessions on the weekends or after-hours are billed at my highest hourly rate (not at a sliding scale).
• Payments I take PayPal and Venmo.
• A credit card will be kept on file, and is required to hold your appointments. I will NEVER charge your card without speaking with you first. I keep card information locked behind two locks, per Texas law. Your card will reserve the appointments you make, and will be used to cover fees which may be outstanding, such as missed-session fees. (Read more about missed session fees in the Appointments and Cancellations section of this document.)
• I am not on any insurance panels, but if you live in the state of Texas, I would be happy to supply you with a receipt AT THE END OF EACH YEAR which you may use to file for out of network reimbursement.

Services Offered:
• I offer counseling and hypnotherapy services for adults by phone or internet phone. I hold a Masters Degree in Counseling from St. Edward’s University, and am fully licensed as a Marriage and Family Therapist in Texas. I am a certified hypnotist. If you live outside the state of Texas, I will be working with you under the title of “Life Coach”, as my counseling license is valid only within the state of Texas.
•How long therapy will take?    Many issues can be addressed within short-term therapy (about 12 sessions), but more serious issues such as trauma, long-standing grief, relationship issues, childhood issues, abuse or addictions usually respond better to longer-term therapy. A good rule of thumb is that it takes one year of clinical work for every decade lived in a state of distress, pain, irresolution or dysfunction.   If you work with me, plan on longer-term therapy (6 - 24 months).
• You are in charge of your personal growth program. If you are struggling in therapy, it's your job to say something. If you don't like a practice we've been doing - speak up. If you'd like to go in a different direction - tell me. HELP ME HELP YOU. I am here to support you in your journey, assess the issues from an impartial, educated perspective, offer a safe and compassionate processing space, and engage you in new ways of working with your issues.

Appointments & Cancellations:
• 24 BUSINESS HOURS' notice is required to cancel an appointment without incurring charge.
• The full fee will be incurred for missed sessions. Please cancel with 24 hours notice to avoid these fees. He who forgets a session, pays for the session. I have never missed a session in my career. However, if I ever do, your next appointment will be free.
• The first 12 sessions will be scheduled weekly in order to build our relationship with rapport and trust. These first 12 consecutive weeks are vital in mastering the hypnosis work. Cancellations will only be accepted for illness... otherwise it is our agreement that you make your appointment each week.
• Email or Text are my preferred modes of communication, and are the fastest way to get a hold of me. I do not check phone messages at all, as I’ve moved the totality of my business online. My email address is Paige@PaigeBartholomew.com.
• If there is an unavoidable emergency, the cancellation fees may be waved. This will be decided on a case by case basis.

Hours of Operation:
• I live in Texas where the time zone is “Central”. I generally work between the hours of 11 am and 8 pm, Central time. If you live overseas, please plan accordingly for phone or online communication sessions.

Complaints: If you would like to make an official complaint to the Texas Board of Licensed Marriage and Family Therapists, please write to:
Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369

"I understand that this form is required BEFORE my first session. If the form isn’t submitted on time, the session will be re-scheduled. My signature acknowledges that I have read, understood, and agree to the contents of this informed consent ."

* Indicates required field

Name *

First

Last

Date *

Email *

Phone Number (if doing phone therapy) *

Time Zone *

Credit Card Number (Required) *

Expiration Date *

3 Digit Code on Back of Card *

Billing Zip Code *

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