Disclosure, Treatment, and Fee Agreement

DISCLOSURE, TREATMENT, AND FEE AGREEMENT

Julie Unger, LPC, NCC 6638 W. Ottawa Avenue, #160-2 Littleton, CO 80128 720-480-1428

Degrees and Credentials: M.A. in Professional Psychology, Licensed Professional Counselor in the State of Colorado, National Certified Counselor.

Regulation of Psychotherapy Practice: The Colorado State Department of Regulatory Agencies regulates the practice of psychotherapy for licensed and unlicensed psychotherapists. Concerns regarding the practice of psychotherapy may be directed to the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite #1340, Denver, Colorado 80202, (303) 894-7766.

Client Rights and Important Information: Method of Treatment: You have the right to know about the treatment methods and counseling techniques used, the duration of therapy if known, and the fee structure. At anytime you may seek a second opinion or terminate treatment. Please be advised that in a professional relationship, sexual intimacy is completely inappropriate and should be reported to the Department of Regulatory Agencies.

Sessions and Fees: Sessions will generally be 45-50 minutes long. The rate for the initial assessment is $125, due at the time of service. After that, the rate is $100 per session, also due at the time of service. If you carry mental health insurance, arrangements will be made for payment of services from the insurance company and you will be held responsible for deductibles, co-payments, non-covered services, or unpaid balances. The following services will be billed at $25 per quarter hour, payable at the next scheduled session: phone calls over five minutes; email exchanges; special letters or reports; consultations with other professionals; court time and other professional services rendered by me at your request. There will be a charge of $25 for missed appointments or cancellations less than 24 hours prior to your scheduled session. If checks are returned for “non-sufficient funds”, all bank fees will be charged.

Confidentiality: Sessions are confidential. Information regarding treatment may be shared with a third party only with written consent from the client. Exceptions to confidentiality include when the client is in imminent danger of harming self or others, when child or elder abuse is suspected and when certain subpoenas are served. In the case of working with minors, legal guardians will know about the treatment, though privacy will be respected as much as possible. When treating couples and/or families, it will be attempted to maintain individual confidentiality among family members, but it can not be guaranteed.

Other Sources of Help: Where appropriate, I will refer you to local resources that might be of help to you. If I think medication might help you, I will refer you to your primary care physician or to a psychiatric provider. I am often available after hours for very brief calls, but if you have a psychiatric emergency, you should call 911 or go to the nearest emergency room.

Statement of Understanding: I have read and understand my client rights and I consent to receive treatment from Julie Unger, L.P.C., N.C.C.

______Client Date

______Therapist Date

______Parent or guardian if client is a minor Date