OUTPATIENT SERVICES CONTRACT
Welcome to Dunn’s Integrity Counseling Services! Please read this document carefully and jot down any questions you may have so that they may be discussed at our next meeting.
Psychotherapy involves discussing unpleasant aspects of your life that may result in uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. For therapy to be successful it calls for your active participation to work through these feelings. There are no guarantees, but therapy often leads to better relationships, solutions to specific problems and significant reduction in feelings of distress.
The first few sessions will involve an evaluation of your needs based upon the presenting problems. At the end of the evaluation process together we will work on develop a treatment plan for services. Sessions are scheduled for 50 minutes per session based upon the agreed frequency and duration of services. The fees for services are sixty ($60.00) per session. Payment is expected prior to each session beginning. A twenty-four (24) hour notice is required for cancellation of services. Appointments are rescheduled at the discretion of availability at Dunn’s Integrity Counseling Services.
Be advised there are charges for other additional services such as telephone consultations lasting longer than fifteen (15) minutes, report writing to include treatment summaries, and attendance with other professions on your behalf. Fees for these services will be at the stated hourly rate. The charge for preparation for legal documentation or appearances and legal appearances on your behalf for testimony is one hundred ($100.00) per hour.
To maintain treatment confidentiality all records will be maintained in a secure location. No information will not be disclosed without written consent and maintained per HIPAA policy. To avoid misunderstanding from non-clinical professionals a treatment summary will be provided upon request and you will be billed accordingly. Please be advised that Dunn’s Integrity Counseling Services is a mandated reported of any forms of suspected abuse or neglect of children and adults with or without established disabilities.
Periodically, I may seek consultation from other clinical professions. Every effort will be made to conceal your identity to maintain the integrity of our clinical relationship. Therapy involves a commitment of time, energy and finances therefore in the event the relationship between Dunn’s Integrity Counseling Services and yourself becomes incompatible every effort will be made is referring you to another clinical professional
If the account has not been paid within sixty (60) of services and arrangements have not been agreed upon legal options will be secured by Dunn’s Integrity Counseling Services to secure payment. This may involve utilizing a collection agency or filing a legal small claim.
Please feel free to contact me at (863) 337-6493. If I am unavailable, please leave a message and I will return the call the same day if possible. In case of emergency, seek assistance at the nearest hospital emergency room, or dial 911 for assistance. Office hours are 9AM to 5PM with call-in hours on Wednesday. No services are available on weekends or holidays.
Dunn’s Integrity Counseling Services
Your signature below indicates you have read the terms of the Outpatient Services Contract and agree to abide by its terms.
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Client’s Printed Name Client’s Signature
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Date
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Veronica Dunn
Licensed Mental Health Counselor
Florida License Number: MH22650
1440 Kathleen Rd
Lakeland,fl 33805
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