FORMS
Counseling Session
Informed Consent for Treatment
Individual Intake
Couples or Family Intake
Copy of Informed Consent
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Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the State of Minnesota are protected by the Client Bill of Rights.
RATES AND INSURANCE
$150 per 50 minute session
$225 per 80 minute session
The first session (intake session) is a 80-90 minute session ~ $225.00.
I am a fee-for-service provider and therefore do not accept insurance.
Payment for sessions are due at the time of service. All charges incurred are the responsibility of the client. I also offer longer session times, an approach that has been shown in research to result in better outcomes.
CANCELLATION POLICY
If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment.
A full session fee is charged for missed appointments or cancellations with less than a 48-hour notice unless it is due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for, or cancel an appointment.
CONFIDENTIALITY AND PRIVACY NOTICE
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
Exceptions include:
Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
Please contact us with any questions you may have on your visit, forms, my policies or rates.
Release of Records
Laws and standards require that we keep records of services provided to clients. You are entitled to receive a copy of the records. It is standard for you to receive a summary of services provided upon request. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. Therefore, if you wish to see your records, it is recommended that you review them with your therapist so that you can discuss them with him/her. If another professional has referred you to Reconnect Counseling LLC you will be asked to sign a General Authorization Form to allow your therapist to consult with the referring professional. You have the right to decide whether or not to sign the General Authorization Form. Full Record Requests must be submitted to the provider in writing. After written submission has been received and all fees are provided, records will be received within 30 days of the initial request and payment. Cost of a request for records is $1.41 per page for copy, plus $18.80 for time spent retrieving and copying the records. Record request made by email are require in writing submission and will be completed by the provider within the above timeframe and fee requirements.
COURT PROCEEDINGS
I would not be considered an expert in a case of divorce or other custody situation. If I am served a subpoena to attend court or if for any reason your records are requested for court proceedings or your therapist is asked to testify in court, I require an advanced notice of at least 30 days prior to the scheduled court date. In addition, our standard fee for an appearance in court regardless of actual time spent in court is $2000/day. This fee is set to compensate the therapist for time taken away from billable time and for any associated costs with the appearance in court. If any hourly costs incur a rate of $250 an hour is subject to be paid by the client requesting all forms. I cannot release any documentation without consent from all parties present in therapy.