Dr. Sara Markese, Ph.D.
Licensed Clinical Psychologist
Therapy at the Square
11198 Lee Highway, Suite D2
Fairfax, VA 22030
917. 545. 8298
Office Policies and Therapy Contract
Practice Policies and Procedures:
Welcome to Therapy at the Square. This document contains important information about Dr. Markese’s professional services
and business policies. Please read these policies prior to your intake appointment, make sure you understand the information
provided about your therapy and ask any questions that you have during the intake process, and then sign/date the bottom.
These guidelines will be made available to you to review and keep for your records.
Sessions:
Following the initial phone consultation, the therapist will schedule the first of two 60 minute intake evaluation sessions with
either the adult client, or the child/adolescent client’s parents/legal guardians. For adult clients, a second intake session will be
scheduled. For child/adolescent clients, a second 60 minute intake evaluation will be scheduled for the therapist to meet with
the child/adolescent client.
Following the intake session/s, therapy sessions will be scheduled once a week for 45 minutes with a given time considered
“blocked” or scheduled weekly for that particular client for the duration of their therapy. Fees for missed appointments are not
covered/reimbursed by insurance, and the credit card on file will be billed on the date of the missed appointment.
Fees:
The hourly rate for therapy and other services provided outside the therapy session is $200 per hour, with the exception of
services related to legal proceedings ($250 per hour). Adult client, parent, and child client 60 minute intake sessions are $200.
Fees for weekly individual therapy are $150 per 45-minute session. Fees for family therapy sessions are $180 per 45-minute
session.
Because the therapist does not participate directly in any insurance plans, the client is responsible for payment in full of all fees
at the end of the session, or at the time service is provided, by check or credit card. Clients will receive a receipt which they
may then submit to their insurance provider in order to be reimbursed if they have out-of network mental health benefits.
In addition to weekly appointments, the therapist will charge the same hourly rate for other professional services the client may
request. These services can be broken down into partial hourly rates (see Fee Schedule attached) but are not covered/reimbursed
by insurance. Other services include report writing, telephone conversations and consultation (at the client’s request) with other
professionals, agencies, or teachers/schools, preparation of records or treatment summaries, and time spent performing any
other service requested. Fees may increase periodically.
Missed Appointments and Cancellations:
Once treatment begins, an appointment hour is considered to be scheduled weekly for the duration of therapy. The client will be
expected to pay the full fee for the session regardless of circumstance, with exceptions outlined below. Please note that
insurance companies do not cover/reimburse for missed appointments.
Illness/Emergency: Events/emergencies beyond the client’s control may arise, and it may not be possible for clients to cancel
24 hours in advance. The entire session fee will be waived in the case of illness or emergency one time per calendar year. If
possible, appointments missed due to illness/emergency will be rescheduled.
Vacation: Clients are allowed 3 sessions of scheduled vacation per calendar year with no session fee. Any vacation scheduled
by the therapist, or sessions missed due to therapist illness will of course not be charged and attempts to reschedule will be
made.
Aside from these exceptions, sessions missed for any reason, without 24 hour advance cancellation, will be billed at the full
$150 session fee. If the client must miss a sessions for any reason, calling 917-545-8298 to cancel 24 hours in advance will
result in the incurrence of a $75 missed appointment fee in lieu of payment of the full $150 session fee.
Late Arrival to Session: If the client arrives late for a scheduled appointment, only the remainder of the 45 minute session will
be available. If the therapist is running late with a prior appointment for some reason, the client will still receive the full 45
minutes. The therapist will contact the client directly if unable to be in the office for any reason (i.e. weather, illness etc.)
Summary of Cancellation Policy:
Once an ongoing appointment hour is scheduled, the client will be expected to pay the full fee for the session weekly. The
client may schedule 3 sessions of “client vacation” in advance without any session fees. The missed appointment fee will also
be waived for 1 session cancellation (under 24 hours notice) due to client illness or emergency. In addition, the therapist will
notify the client in advance of the weeks the therapist will take vacation. If the client must cancel outside of the above
instances, cancellation 24 hours in advance, so the therapy time may be given to another client, will result in the charge of a
missed session fee of $75, rather than the full session fee of $150.
In order to facilitate compliance with the cancellation policy, the therapist will keep a credit card on file for all clients.
All information will be kept confidential in a locked cabinet with other client files. While all clients must agree to maintain a
credit card on file for payment of all missed appointment fees, other therapeutic services and any delinquent accounts, clients
will also be given the option to authorize the therapist to charge all services rendered on the card on file.
Please note that insurance companies do not cover/reimburse for missed appointments. As a result these charges are the entire
responsibility of the client. The therapist will charge missed appointment on the date of the missed session, either a $75
cancelled session fee (24 hours notice) or a $150 missed session fee (less than 24 hours notice). In the case of payment for
additional services, the client will be informed of the total cost before any charged are made. In the case of delinquent
accounts, the therapist will make every attempt to contact the client to arrange payment before charging the full amount on the
card. The therapist also has the option of using legal means to secure the payment, which may involve hiring a collection
agency. If such legal action is necessary, these costs will be included in the claim. There will be a $30 charge for the return of a
check from the bank.
Insurance Reimbursement:
As a solo-practitioner, Dr. Markese does not have the administrative resources to participate in any insurance programs. Dr.
Markese is licensed in Virginia as a Clinical Psychologist, and the client’s insurance company may provide partial
reimbursement for session fees according to guidelines they have established for out-of-network providers. Most health
insurance policies provide some coverage for mental health treatment, and Dr. Markese will provide a comprehensive receipt
for services which the client may submit to insurance in order to receive the benefits to which they are entitled.
However, the client (not the insurance company) is responsible for full payment of all fees at the time of service. Please refer to
the Out-of-Network Benefits Guidelines Form for information about how to find out exactly what mental health services the
insurance policy covers. It is advised that client’s call their plan administrator to ask all questions about coverage. Also, clients
should carefully read the section in the insurance coverage booklet that describes mental health services. In most cases,
insurance companies require the client to authorize Dr. Markese to provide them with a clinical diagnosis, and in some cases,
additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). With the
client’s consent, this clinical information then becomes part of the insurance company files.
Forensic and Litigative Services:
For professional and clinical reasons, Dr. Markese does not participate in court proceedings of any type, unless compelled to do
so by court issued subpoena. If the client becomes involved in legal proceedings that require therapist participation, the client
will be expected to pay for all of the therapist’s professional time spent on matters related to court proceedings, including
preparation of client records, telephone time in consultation with attorneys or agencies, preparation for and appearance at
deposition and court hearings, transportation costs, report writing, and consultation and supervision with other professionals,
even if called to testify by another party. Because of the complexity of legal involvement, the therapist charges $250 per hour
for preparation and attendance at any legal proceeding other than in-court testimony. Appearance in court will be billed at
$2,000 per appearance, to be received two weeks in advance.
Contacting Dr. Markese:
Please contact the therapist at (917) 545-8298 to discuss any clinical matters or to cancel any appointments. Due to being
involved in therapy sessions throughout the day, the therapist is often not immediately available by telephone despite being.
usually in the office between 9am and 5pm. If you are unable to reach Dr. Markese, please leave a message on the voice mail
indicating the reason for your call, and every effort to return your call on the same day will be made, with the exception of
weekends and holidays. In order to facilitate contact, please include in your message some times when you will be available.
If you are unable to Dr. Markese in the event of a crisis or emergency, please contact your family physician or the nearest
emergency room and ask for the psychologist or psychiatrist on call. While every attempt will be made to assist the client in the
event of a crisis or emergency, due to the nature of private practice, Dr. Markese is not able to provide crisis, on-call services.
If unavailable for an extended time, Dr. Markese will provide the client with the name of a colleague to contact, if necessary,
and the information will be accessible on the therapist’s voice mail. Dr, Markese only uses email for setting up appointment
times, contacting client who have missed an appointment, or sending forms to clients. Email is not used by Dr. Markese for
discussion of clinical issues as email is not a secure, confidential form of communication and is not appropriate for urgent
communication. The client may choose to email Dr. Markese for scheduling or to provide weekly information and/or updates
on client activities and functioning with these considerations in mind, and knowing that all written communications will be
included in the client’s chart.
Professional Records
Dr, Markese is required by the laws and standards of the psychology profession to keep treatment records for all clients. While
clients are entitled to receive a copy of their records, in the event that this will not cause substantial harm to the client, Dr.
Markese strongly recommends that the client receive a treatment summary in lieu of the release of full treatment records.
Treatment files are professional records that may be misinterpreted by and/or upsetting to untrained readers, and that may be
harmful if released in the case of minors. The review of records, if necessary, should be done with the therapist so that the client
and therapist may discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding
to information requests.
Minors
For clients under 18 years of age, the law may provide parents the right to examine a minor’s treatment records. It is the
therapist’s policy to request that parents are provided only with general information about sessions with minors as
confidentiality and privacy are an important part of the therapeutic process for clients of all ages. If possible and appropriate,
before giving parents any specific information disclosed by the minor, the therapist will discuss disclosure and concerns with
the child/adolescent and attempt to help the minor to disclose the information with the parents in a family session.
In the case that there is a high risk that the child/adolescent will seriously harm themselves or someone else, parents will be
notified of any concerns immediately. Dr. Markese will also provide parents with a summary of the child/adolescent’s treatment
if requested.
Confidentiality
In general, the law protects the privacy of all communications between a client and a psychologist, and the therapist can release
information about treatment to others only with the client’s written permission. Exceptions include situations in which Dr.
Markese is legally obligated to take action to protect others from harm, in which case the therapist may have to reveal some
information about a client’s treatment. For example, in the case of suspected abuse/neglect of a child, elderly, or disabled
person, Dr. Markese is required by law to file a report with the appropriate state agency. If Dr. Markese believes that a client is
threatening serious bodily harm to another, the therapist may be required to take protective actions. These actions may include
notifying the potential victim, contacting the police, or seeking hospitalization for the client.
If the client threatens to harm himself/herself, Dr. Markese may be obligated to seek hospitalization for the client or to contact
family members or others who can help provide protection. Every effort to fully discuss this mandated disclosure will be made
before any actions are taken.
In most legal proceedings, the client has the right to prevent the therapist from providing any information about treatment.
However, in some proceedings involving child custody and those in which the client’s emotional condition is an important
issue, a judge may order Dr. Markese’s testimony if the judge/court determines that the presenting issues demand it.
Dr. Markese may occasionally find it helpful to consult other professionals about a client’s treatment in order to best serve the
client’s needs. During a consultation, the therapist will make every effort to avoid revealing the identity of the client, and the
consultant is also legally bound to keep the information confidential.
----------------------------------------------------------------------------------------------------------------------------------------------- ----------I understand and agree to the above arrangements and have been offered a copy of these guidelines for my files.
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Adult Client / or Client’s Legal Guardian Signature
Date
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Therapist Signature
Date