Informed Consent

Thank you for choosing my practice on your search for support. This document contains important information about my professional services and business policies. Although it may seem lengthy and complex, your understanding of it is key, as signing it represents an agreement between us. We can discuss any questions you have in advance of signing or any time in the future.

Therapeutic Process

Beginning psychotherapy is an important step and involves benefits and risks. Risks include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, or frustration, as therapy involves discussing life’s challenges.  Extensive research shows therapy has many benefits. The safe, accepting environment and skills developed through therapy can support a significant reduction in distress, increased relational satisfaction, greater awareness and insight, improved management of thoughts, feelings, and behaviors, and enhanced problem-solving abilities.  That said, there are no guarantees about the outcomes of our work together. Progress requires consistent and active effort on your part. Your action toward your needs and goals between sessions is the strongest determinant of success. I cannot promise your circumstances, thoughts, emotions, or behavior will change; however, I can promise to do my very best to understand and support you, and help you clarify what it is you want for yourself.

Our first session will focus on your concerns, needs, goals, and expectations for the therapeutic process. These are essential elements of our work that we will revisit over time. Additionally, I will offer initial impressions of what our work might include. As we begin working together, you should assess whether you feel comfortable working with me. You have the right to ask questions about any aspects of therapy, my approach, and my training and experience whenever they arise.

Non-Discrimination

If you are unhappy with what is happening in therapy, I hope you will talk with me so I can hear and respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request I refer you to another therapist and are free to end therapy any time. You have the right to considerate, safe, and respectful care, without discrimination based on race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.

Attendance

Sessions are approximately 45 minutes in duration weekly or biweekly at a time we agree on, although some sessions may be longer or more or less frequent as needed. To remain an active client with this practice, we must routinely meet at least every eight weeks. For regulatory compliance, your chart will be closed if we have not met within 90 days and can be reopened to resume our work upon your request.

Your appointment time is assigned to you alone. You are responsible for coming to your appointment on time; if you are late, your session will still need to end on time. Arrival 15 or more minutes past your scheduled start time will be considered a missed appointment. At least two calendar days of notice by phone is required to cancel an appointment. Cancelling or rescheduling a session on the calendar day prior to the appointment will result in a fee of $50. Cancelling or rescheduling an appointment on the calendar day of the appointment, or missing an appointment without advance notice, will result in a fee of $100. These fees are not insurance reimbursable and apply to all, regardless of payment method. Exceptions are only made in the event of a serious emergency.

It is not appropriate to incur excessive costs for unused session time. As such, more than three missed sessions without advance notice in any six month period likely means it is time to end our work together, even if temporarily. In this case, I will gladly assist you with any information or resources needed for continued or future support.

Payment for Services

Insurance Participation

I am a participating in-network provider with a variety of health insurance carriers. These include most plans offered by Aetna, All Savers (UHC), Allied Benefit Systems, Christian Brothers Services, GEHA - United Healthcare Shared Services, Harvard Pilgrim, Health Plans Inc., Health Scope, Medica, Meritain, Nippon, Optum, Oscar, Oxford, Surest (formerly Bind), United Healthcare (as well as Exchange, Global, Shared Services, and Student Resources plans), Trustmark Health Benefits, Trustmark Small Business Benefits, and UMR. I also welcome members of the Optum Live & Work Well and Optum Emotional Wellbeing Solutions employee assistance programs (EAP). I am an out-of-network provider with all other health insurance carriers. Please note I do not participate with Medicare or Medicaid in any form. Your out-of-pocket cost per session is determined by your insurance carrier based on plan specifics, in-network deductible status, and co-insurance percentage or co-payment amount. Please note that I participate with a provider community called Alma, which will correspond with you regarding insurance eligibility, claims, and associated payments. Information shared with Alma will be limited to the minimum required to fulfill these activities.

In some cases, our work may not be eligible for insurance coverage. Examples include telephone-only therapy sessions or when therapy is not medically necessary. In these circumstances, we will explore alternative coverage and/or payment options as soon as possible.

Standard Rates

Standard self-pay rates for individual therapy sessions are $120.00 per 45-minute session and $160.00 per 60-minute session. You may seek personal reimbursement through your health insurance plan's out-of-network benefits; I will provide you with a detailed superbill following each session to assist with this process at your request. I am not able to provide superbills retroactively nor submit out-of-network claims on your behalf, and out-of-network coverage is not guaranteed. A prorated fee of $80.00 per hour applies with advance notice for any additional professional service you request, such as report writing, telephone conversations, meeting attendance, or other forms of professional collaboration, when amounting to over 15 minutes in any given calendar week.

Payment Processing

All major credit and debit cards, including Visa, MasterCard, American Express, and Discover, Health Savings Accounts (HSA), Flexible Spending Accounts (FSA), and some wellness cards are accepted as payment. A payment method must be kept on file in order to begin therapy. By enrolling in our autopay system with the card of your choosing, you agree to automatic charges for the cost of sessions attended, missed, and/or cancelled late at the rates outlined earlier in this agreement.

You are responsible for full payment at the time of each session unless prior arrangements have been made. Mindful of the medical debt burden, I do not offer payment plans at this time; we will need to pause scheduling if there is a balance due on your account.

Financial Hardship

I believe we all have a right to high quality interpersonal support regardless of income or ability to pay. The following resources enhance service accessibility and do not affect the nature or quality of our work. I hold limited space for negotiated rates through the Open Path Psychotherapy Collective. This option is subject to availability and appropriate for individuals who are uninsured or underinsured and experiencing financial hardship. Learn more at https://openpathcollective.org. Black women seeking financial assistance may be eligible for 4 to 12 45-minute individual therapy session vouchers through the Loveland Therapy Fund. Learn more at https://thelovelandfoundation.org/therapy-fund/.

Confidentiality and Communication

You have been provided with a document entitled Notice of Privacy Practices, which outlines the Health Insurance Portability and Accountability Act (HIPAA), a federal law providing privacy protections and patient rights for use and disclosure of Protected Health Information (PHI) for treatment, payment, and health care operations purposes.

If we accidentally see one another in public, I will not acknowledge you first; your confidentiality is of great importance to me and I will not jeopardize your privacy. If you acknowledge me first, I will happily speak briefly with you, though I typically find it inappropriate to engage in lengthy discussions outside of the therapy office. In accordance with my personal and professional ethics, I will not pursue any form of personal relationship with you outside of our working professional relationship.

When communicating about personal matters, you may contact me by phone at (716) 222-9066 or secure message in the online client portal. Encrypted e-mail is used for initial inquiries and business matters only, as it may pose added security and confidentiality risks. In order to preserve your information security, I am unable to communicate about therapy via text message. By signing this agreement, you consent to the electronic transmission of information necessary for the therapeutic process or upon your request. I am often not immediately available by telephone and do not answer calls when in session or otherwise unavailable, and am not considered to be on-call. At these times, you are encouraged to leave a confidential voicemail, available 24 hours per day and 7 days per week, and your call will be returned by the end of the next business day. If you are unable to reach me and feel unable to keep yourself safe, or in the event of an emergency, please go to your local hospital emergency room or call 911. Should you need immediate support before I am able to respond, please consider calling 988 for the Suicide & Crisis Lifeline.

I look forward to our work together and welcome you to what I hope is a meaningful and rewarding process!

Informed Consent Effective March 17, 2018
Last Revised March 20, 2025