Sushma S Trivedi, MFT
License # 47584

Client Agreement

FEES:     Fee for the session is due at the start of the session.  Each session must be paid for at the time of service.  

APPOINTMENTS:    I have a 24-hour notice of cancelation policy. Should you not show up for an appointment and do not cancel  prior to the 24-hour period, you will be charged for the missed session. If you do not pay for an appointment, we ask you to bring the payment to the next session. If payment is past due for three sessions, no further appointments may be scheduled until arrangements for payment have been made with me.

SESSIONS:    Sessions are 50 minutes in length, unless specified otherwise.

SESSION FEE:      $160.00  per session.  Sliding scale fee may be available in some cases.

CONFIDENTIALITY:  Any information disclosed to me by yourself or any member of your family is confidential. It will not be released to anyone without your signed written consent except as mandated by law, i.e., when there is reasonable suspicion of child, elder or dependent adult abuse, or there is reasonable suspicion that you pose a danger to yourself or others. 

While working with couples, I have a no secrets policy.

Case information may be discussed in peer consultation for improvement in quality of service; or for research and educational purposes.  In such cases your identifying information will be disguised so that confidentiality is not compromised.

AVAILABILITY BETWEEN AND OUT OF SESSIONS:  In case of emergency, please call 911 or go to your nearest hospital. If you need to consult me between sessions, you can call me.  I shall make every effort to return your call within 24 hours.  If needed, I make an effort to interact with other professionals involved in the care of my clients (for example, meeting with your child’s teacher, or speaking with your doctor or psychiatrist).  I charge $30 per each 10 minute time slot.  Same charge applies to email communications, copying of records, or any other service that requires my time.

LEGAL REPORT AND/OR TESTIMONY:  In case I need to get involved in legal matters that pertain to you (such as writing reports for the court system, court appearance, etc.), I shall charge $300 per hour for my time and bill you for the expenses.

EMAIL COMMUNICATION:  Since email communication may not be secure, I shall communicate with you on email with your permission. If you send me an email or request information by email I shall comply.  My email is password protected. You will be responsible for maintaining the confidentiality of such communication at your end. 

In order to maintain the integrity of the therapeutic process, I will not be your “friend” on social networking sites.

ABOUT PSYCHOTHERAPY: I suggest that you read the Frequently Asked Questions under the tab FAQ.  You have the right to end therapy anytime.  I shall be glad to provide you with referrals to other therapists if you like.

 

 

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    Client Signature