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Therapy Agreement

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Client Worksheet

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Therapy Agreement

Therapy Contract and Consent for Treatment

Karen Turiel Klein, LCSW-C

 

 Welcome to Karen Klein’s office. Unlike most doctor/patient interactions, the therapy relationship is a very personal one. The process of psychotherapy requires your active participation. The goals, particularly in the early stages, are to create a trusting and increasingly open therapeutic relationship. An investment in this process will most likely involve exploring complex life issues. This takes great courage and commitment.

This agreement serves as your consent for treatment. What is outlined in the following paragraphs mostly pertains to those who choose to enter ongoing therapy, and it does not commit you to that process. Choosing the right therapist for you might require you to meet with more than just one therapist. Signing this agreement does not commit you to anything beyond the initial consultation, which can be a time to explore how to best get your therapeutic needs met.

 You will receive an invoice at the end of each month. Payment is not required at the time of service. Fees for all appointments are due by the 15th of the month following service dates.  Payment may be made in cash, check, credit card or PayPal. Current therapy charges are $240 for each 50 minute session. When there is an arrangement made for longer sessions, the hourly fee is prorated to reflect the specific amount of time spent. For phone calls that are over 5 minutes in length, the fee is also prorated.

 The policy for cancellations is as follows: A client contracting for a specific therapy appointment is reserving the time of the therapist at a particular hour every week. Once an ongoing schedule is mutually agreed upon, oftentimes after a few weeks of working together, the client will be charged every week for that hour unless 1) an alternative appointment time is agreed upon 2) Karen is able to fill the hour with another client. Otherwise, the full fee of $240 for therapy is charged. One of the exceptions is when Karen has the need to reschedule the regular therapy hour and you do not wish to reschedule that week. The other is when government offices close due to inclement weather. Though this office might remain open on those days, if traveling does not feel safe for you, there will be no charge for services.

 Once an ongoing therapy agreement is established, if you wish to discontinue sessions it is asked that you discuss this in person during an appointment. It is strongly discouraged that these important changes be made by phone or mail.  The privileged information and confidentiality of communication between a client and a therapist is protected by law, and a therapist can only release information about a client’s therapy with the client’s written permission. The therapist is required by law to report any suggestion of child abuse or neglect to proper authorities. An intention to physically harm oneself or others would also constitute a need to inform authorities. In the case that the therapist will be working with a minor in your custody, signing this form marks your agreement and consent to allow the therapist to work with this minor.

Client Worksheet