Initial Agreement for Psychotherapy, Counseling, Mediation, Conflict Resolution, Integration, and Intensive Services
- I agree to use the services of Barbara Sanders, LCSW.
- For Psychotherapy and Counseling services, I understand that Ms. Sanders will meet with the client for 45 minute sessions (unless more time is agreed upon), and that she will expect payment at each session.
- I understand that my therapy or other services are confidential unless there is an emergency, or a release of information form has been signed by the client.
- The cost for Psychotherapy and Counseling services is $150 per 45 minute session. If Ms. Sanders bills my insurance, I am responsible for the full fee at each session and will allow the insurance company to pay me my benefits.
- For Mediation or Confict Resolution services, Integration services, or Intensive services, I understand that the charge is $200 per hour for Ms. Sanders' work, including but not limited to face-to-face sessions, online or phone sessions, research, administrative work, and writing reports.
Name of the Client(s):__________________________________________________________________
Signature of Client(s)___________________________________________________________________
Other responsible party, if needed __________________________________________________________
Date________________Signature of Provider___________________________________________