ADULT SERVICE AGREEMENT
Welcome to Sundstrom Clinical Services, LLC. We are happy that you’ve chosen us as you
service provider. This document contains important information about our professional services
and business policies that will clarify our mutual obligations. Please read it carefully and jot
down any questions that you might have so that we can discuss them during our meeting. Once
you sign this, it will constitute a binding agreement between us.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It is a process and sometimes it
involves assessment and evaluation to clarify matters. It also varies depending on the training
and personality of both the therapist and the client and the particular problems the client brings.
There are a number of different approaches that can be utilized to address your problems. It is
not like visiting a medical doctor, in that it requires a very active effort on your part. In order to
be most successful, we will work together and you will continue to be active in pursuing your
goals at home or outside your therapy session.
Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable
levels of feelings like sadness, guilt, anxiety, anger and frustration, loneliness and helplessness.
Psychotherapy often requires recalling unpleasant aspects of your history. Psychotherapy has
also been shown to have benefits for people who undertake it. It often leads to a significant
reduction of feelings of distress and better relationships and resolutions of specific problems.
But there are no guarantees about what will happen. It is a process of change.
By the end of our initial evaluation, we will be able to offer you some initial impressions of what
our work will include and an initial treatment plan, if you decide to continue. You should
evaluate this information along with your own assessment about whether you feel comfortable
working with your therapist. Therapy involves a commitment of time, money, and energy, so
you should be comfortable with the therapist you select. If you have questions about our
procedures, we should discuss them whenever they arise. If your therapy discomfort persists, we
will be happy to help you to secure an appropriate consultation with another mental health
professional within our clinic.
MEETINGS
We will usually schedule one 45 minute session per week at a mutually agreed time, although
sometimes sessions will be more or less frequent. As a courtesy we try to make reminder calls
the day before your appointment. However, we do not guarantee that you will always receive a
call. Once your appointment is scheduled you are responsible to keep track of your
appointments. We require 24 hour notice of cancellations. There will be a $75
charge for any missed appointments or late cancellation. All cancellations
must be called in during regular business hours and not left on the answering
machine.
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PROFESSIONAL FEES
Our hourly (45 min. session) fee is $275 for the initial consultation and $175 for following
individual sessions. Family sessions are $205. In addition to weekly appointments, it is our
practice to charge our hourly rate of $100 on a prorated basis for other professional services you
may require such as report writing, telephone conversations longer than 15 minutes, attendance at
meetings or consultations with other professionals which you have authorized, preparation of
records or treatment summaries or the time required to perform any other service which you may
request of us. Insurance companies do not pay for these services in most cases. In unusual
circumstances, you may become involved in a litigation that may require our participation. You
will be expected to pay for the professional time required even if we are compelled to testify by
another party. You will also be expected to pay at least fifty percent of the anticipated fee for
time spent in the form of a retainer. (Because of the complexity and difficulty of legal
involvement, we charge $180 per hour for preparation and travel time and $300.00 per hour for
participation at any legal proceeding).
BILLING AND PAYMENTS
You will be expected to pay for each session at the time services are provided. If you have
insurance coverage, the business office will calculate your estimated copayment to be paid at
the time of service. If you do not have insurance, or if you prefer us not to bill your insurance,
we offer a 25% cash discount, since this saves us the time and expense of billing your
insurance. We accept personal checks, money orders, cash, VISA, and MasterCard. Payments
may also be made over the phone.
We will bill your primary insurance after each appointment. We do not bill secondary insurance.
If there is a client balance due you will receive a statement once a month. The client balance due
listed on the statement is payable upon receipt. A re-billing charge of $10 is assessed each month
on balances over 30 days.
This office does not accept responsibility for collecting your insurance claim or for negotiating
a settlement on a disputed claim. You are responsible for payment of your account, including
any unpaid insurance claims.
If you’d like to request payment arrangements due to extenuating circumstances, please contact
the business office. Client balances that are 60+ days past due may be assessed a 1-1.5% (18%
annual) service charge.
Please note that in the event that you fail to make payment when due, this account may be
referred to a collection agency for collection. In that event, the contingency fee assessed by the
collection agency will be added to the principal and interest due. You will be additionally liable
for attorney fees and court costs. Both collection agency fees and attorney fees will increase the
balance you owe. If your account is turned over to a collection agency, it may affect your credit
rating. In most cases, the information which we release to a collection agency about a client
would be the client’s name, dates of services, contact information and the amount due.
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INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what
resources are available to pay for your treatment. If you have health insurance, it will usually
provide some coverage for mental health treatment. Our office will verify your insurance
benefits as a courtesy to you. Verification of benefits quoted to our office is not a guarantee of
payment. In addition, we will provide you with whatever assistance we can in facilitating your
claim. However, you, and not your insurance company, are responsible for full payment of our
fees. Therefore, it is very important that you find out exactly what mental health services your
insurance policy covers.
The escalation of the cost of health care has resulted in an increasing level of complexity about
insurance benefits, which sometimes makes it difficult to determine exactly how much mental
health coverage is available. “Managed Health Care Plans” such as HMOs and PPOs often
require advance authorization before they will provide reimbursement for mental health services.
These plans are often oriented towards a short-term treatment approach designed to resolve
specific problems that are interfering with one’s usual level of functioning. It may be necessary
to seek additional approval after a certain number of sessions.
You should also be aware that insurance agreements require you to authorize us to provide a
clinical diagnosis, and, depending on the insurance carrier, many require additional clinical
information such as a treatment plan or summary, or in rare cases, a copy of the entire record.
This information will become part of the insurance company files, and, in all probability, some of
it will be computerized. All insurance companies claim to keep such information confidential,
but once it is in their hands, we have no control over what they do with it. In some cases they
may share the information with a national medical information data bank. If you request it, we
will provide you with a copy of any report that we submit. It is important for you to know that
you always have the right to pay for services yourself and avoid the complexities of your
insurance company involvement. As previously stated we do offer a 25% cash discount if
insurance billing is not involved.
Once we have all of the information about your insurance coverage, we will discuss what we can
expect to accomplish with the benefits that are available and what will happen if the insurance
benefits run out before you feel ready to end our sessions.
CONTACTING US
Your therapist is not often immediately available by telephone. Therapists are also not able to
answer the phone while they are with a client. Our receptionists are available to answer phones
during normal business hours, and you may leave your therapist a confidential voice message.
We make every effort to return your call on the same day, with the exception of scheduled days
off, weekends and holidays. If you are difficult to reach, please leave some times when you will
be available. In case of an after hour emergency, the office has a 24-hour phone service. If it is
urgent that you talk with a therapist during this time, you will be instructed to call the emergency
on-call number and leave a message as to the emergency. The on call therapist will then return
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your call. If for some reason these services do not appear to be adequate, you should call your
family physician or the emergency room at the nearest hospital and ask for the psychologist or
psychiatrist on call. In case of inclement weather, please call your therapist’s voicemail to see if
your therapist has canceled appointments for the day.
PROFESSIONAL RECORDS
We are required to keep appropriate records of our work together. These records require
professional explanation, which can be misinterpreted by someone who is not a mental health
professional, therefore it is our general policy that clients may not review them. However, if you
request, we will provide you with a treatment summary unless we believe that to do so would be
emotionally damaging. If this is the case, we will be happy to forward the summary to another
appropriate mental health professional who is working with you. You should be aware that this
will be treated in the same manner as any other professional (clinical) service and you will be
billed accordingly.
CONFIDENTIALITY
Couples
In counseling where the couple is present together, personal, confidential information on each
person is recorded and contained in the same clinical file. When and if there is a need for one
person to access information on self or other from that file, we will protect each person’s privacy
by requiring written consent to release that information from each of you before we would
release that information to either or both of you, or to any other authority or agency.
Adults
In general, law protects the confidentiality of all communications between a client and a
psychologist, and we can only release information about our work to others with your
written permission. However, there are a number of exceptions.
In most judicial proceedings, you have the right to prevent us from providing any information
about your treatment. However, in some circumstances such as child custody proceedings and
proceedings in which your emotional condition is an important element, a judge may require our
testimony if he/she determines that resolution of the issues before him/her demands it.
There are some situations in which we are legally required to take action to protect others from
harm, even though that requires revealing some information about a client’s treatment.
If we believe that a child, an elderly person, or a disabled person is being abused, we must file a
report with the appropriate state agency.
Clients should be aware that all Clinical Social Workers and Master Level Counselors are legally
required to report all instances of child, disabled, and elder abuse. Though Psychologists are not
legally mandated to make a report of abuse when reported within the therapy relationship, many
make it their personal policy to do so. Questions regarding reporting requirements or legal
definitions of abuse should be directed to your therapist.
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If we believe that a client is threatening serious bodily harm to another, we may be required to
take protective actions, which may include notifying the potential victim, notifying the police, or
seeking appropriate hospitalization. If a client threatens to harm him/herself, we may be required
to seek hospitalization for the client, or to contact family members or others who can help
provide protection.
These situations have rarely arisen in our practice. Should such a situation occur, we will make
every effort to fully discuss it with you before taking any action. We may occasionally find it
helpful to consult about a case with other professionals.
Your signature(s) below indicates that you have READ the information in its entirety in this
document and agree to abide by its terms during our professional relationship.
_________________________________
Client’s Name
_________________________________
Client’s Signature
______________________
Date
_________________________________
Spouse’s Signature
______________________
Date
PLEASE RETURN ENTIRE PACKET – You may request a copy for your records.
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SUNDSTROM CLINICAL SERVICES
PROFESSIONAL SERVICE FEES
All payments required at time of visit
Secondary Insurance not billed by SCS
No Guarantee of Insurance benefit quotes
Service
Psychologist Rate
LPC Rate
First Session
Individual Sessions
Family Sessions
Testing/Hourly
$275.00
$175.00
$205.00
$170.00
$225.00
$125.00
$155.00
25% Cash Discount (Non-insurance – CASH clients only)
SERVICES NOT BILLABLE TO INSURANCE
Miscellaneous Fees:
Cancellation Fee
Group Sessions
Insurance Report
Letter Preparation
Medical Records
Medical Record Mailing Fee
Phone Consult
Phone Session
Professional Service
Rebilling Fees
Records Review
Report Writing
Legal Fees:
Hourly Rate (PRO-RATED)
$ 75
$ 30
$100
$100
$ 25 first ten pages - $.10 per add. page
$ 5
$100
$100
$100
$ 10
$100
$100
Hourly Rate (PRO-RATED)________________
Conference with Attorney
Court Appearance/Testimony
Court Preparation
Deposition
Legal Consult
Legal Preparation
Mileage
Travel Time
$180
$300
$180
$180
$180
$180
$ .51/mile
$180
A 50% RETAINER IS REQUIRED
FOR ALL LEGAL SERVICES PRIOR TO SERVICE.
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