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All Rights Reserved © 2019 Designed by Jerica Mitchell

Client Services Agreement

This therapeutic relationship is an Agreement between you and WPFS unless we have already relied on this Agreement to take action or if you have not paid your bill in full.  Finally, this agreement also contains information about a federal law that affects your privacy rights. This law, called HIPAA (Health Insurance Portability and Accountability Act), regulates the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we give you a Notice of Privacy Practices (the Notice). The Notice, explains HIPAA’s application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Please take home the Notice and read it before your next session; you and your therapist can discuss any questions you may have about it next time.

 

Appointments, Hours & Locations

Individual appointments last approximately 50 minutes and can be scheduled by calling (832) 685-6518 emailing our office, or logging into the client portal. Please leave a message. If you need to cancel an appointment, notify us at least 24 hours before your appointment, or you will be charged a $50 fee for the missed session. However, if you call in advance to cancel an appointment because you are ill, there will be no charge. Therapy can be conducted in your home, over the phone, by video conference, or in the therapist's office. If we need to drive to meet you in a location other than our office, a mileage charge of $0.75 will be added to your bill for every mile traveled beyond the first 3. Mileage is calculated from the therapist's starting point and is added only to clients not paying the full fee per hour. Clients paying full fee will only be charged for mileage if travel of more than 20 miles from the therapist’s starting point is required.

 

Telephone Calls, Emails,  Texts and Emergencies

If you receive my voice mail, please leave a message and Dr. Wilson or another staff member will get back to you as soon as is feasible, usually within 24 hours. Lengthy telephone consultations beyond 15 minutes may be prorated and billed at a standard hourly rate for professional service. We may be able to respond more quickly to email or texts, but note that these are not secure ways to contact our clinicians. If you text your clinician and don’t hear back within a few hours, please email or call the office. If your therapist am out of the office for an extended period of time, her outgoing message will let you know who is covering for her. It is not always possible to set up an auto-responder for text messages. When your therapist is not available and do not have someone covering for her and you need to talk to someone, please call the 24-hour Crisis Line in Houston at 832-416-1177 or in San Antonio at 1-800-784-2433.  In emergencies, please call 911 or go to a hospital emergency room. An emergency is generally a situation in which you are in danger of harm or have hurt yourself or someone else.

Confidentiality

The laws governing confidentiality can be quite complex.  We will maintain a Clinical Record file on your case, which is the property of  WPFS. You may examine and/or receive a copy of your file if you request it in writing and the request is signed by you  and dated not more than 60 days from the date it is submitted. There may be a charge for writing reports or for copying materials. In most situations, we can release information about your treatment to others only if you sign a written authorization form for each release. However, we are mandated to report and there are a few situations where she is required to disclose information to authorities. These situations are listed below.

 

  • If a client is likely to seriously harm him/herself, we may be required to take action to prevent self-destruction.

  • If there is a clear risk that a client plans to seriously harm another person, we may have a duty to warn the potential victim; or disclose the risk to appropriate public authorities.

  • If he suspects that abuse of a child or senior citizen may have taken place, we are required to report the

  • suspected abuse to Child or Adult Protective Services.

  • If the client is a minor younger than age 18, both parents have access to the minor client’s complete Clinical Record, including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access, or it is potentially harmful to the child for a parent to have access to the child’s Clinical Record.

  • If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. We cannot provide any information without your (or your personal or legal representative’s) written authorization.

However, for court orders or subpoenas we are required by law to disclose requested information.  If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

Fees for Therapy, Assessments and Overall Financial Agreement

The standard fee for in office Therapy is $150 - $190 per 50-minute session.  Prices vary for Telehealth, Assessments and Evaluations.  However, quality healthcare should be available to everyone. In keeping with this belief, a sliding fee scale is provided for clients who may be unable to pay the full fee. Should your financial situation improve, I encourage you to remunerate the remainder of your fee. This will allow me to continue to serve everyone in the best possible way regardless of financial situations. Proof of gross annual income may be required to be placed on the sliding fee scale.  A session is generally 50 minutes in length with 10 minutes for record keeping. Longer sessions are charged at a prorated fee.

 

Fee Agreement

 

1. Fee Increases:

Occasionally, WPFS may increase the standard fee. If you are in therapy when an increase is to occur, you will be notified in advance, and given an opportunity to discuss the fee increase. 

2. Payments:

All fees are payable in full at the time of service by cash or credit card. Overdue accounts may be charged interest at the rate of 10% per year.  However, all payments are due at the time of service.

 

3. Collection Procedures:

WPFS reserves the right to collect any unpaid balance.  We may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record.  Clients will be notified in writing before WPFS takes action to collect.