Psychotherapy Services Agreement

Psychological Services for Individuals

Psychotherapy is a complex process. My process varies depending on your personality and mine and the relationship that we create. I will be relying on many different therapeutic approaches as we address the issues and concerns that you bring to the session. The process of psychotherapy is different from other medical services. It calls for active effort on your part. For therapy to be most successful, you will need to be engaged with the process both during our sessions and outside of the therapy hour.

Psychotherapy can have benefits and risks. It often involves discussing challenging aspects of your life, leading to uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. The objective, of course, is to change your life for the positive, leading to better relationships, resolution of specific issues, and significant reductions in feelings of distress. I cannot guarantee what you will experience.

My usual procedure is to schedule an initial consultation/ evaluation that will take one to three sessions to complete. During this period, we both can evaluate whether we are a “good fit” to work together productively. If you have questions about my procedures or how I practice, we can discuss them whenever they arise. Assuming that we continue to work together, you always have the ability to stop any session or our therapy relationship at any time. I encourage you, however, to share your thoughts and feelings so that you are in a position to make an informed decision, and not one based on a possible misunderstanding.

Individual Sessions

I typically schedule one-hour (50 minute) sessions for individual psychotherapy. Once we initiate psychotherapy, I generally recommend that we schedule one session weekly at a mutually agreedupon time at least for the first month, and often recommend that we meet every other week after that. Circumstances may justify more or less frequent sessions.


My fees for individual therapy sessions are:

  • Intake/ evaluation session: $170;
  • Follow-up sessions: $150.

You will be expected to pay for a scheduled session unless you provide at least 24 (workday) hours advance notice of cancellation or we both agree that you were unable to attend due to circumstances beyond your control. Insurance companies do not provide reimbursement for missed or cancelled sessions. In those circumstances, you will be responsible for my full hourly fee, not simply the copayment or coinsurance amount.

I charge $150 per hour for other professional services you may need, though I will prorate the charge to the actual time I work. These other services include letter or report writing, telephone conversations with you or on your behalf, preparing records or treatment summaries, or any other service you request of me.

If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200 per hour for litigation-related services.

Contacting Me

Often, I am not immediately available by telephone. You are welcome to leave a confidential message on my voicemail. I will make every effort to return your call on the same day that you make it with the exception of weekends and holidays. If you are unable to reach me and you need immediate psychiatric assistance, call the University Neuropsychiatric Institute’s crisis line at 801.587.3000. UNI can reach me if I am in town. If I will be away for an extended period, I will leave the name and phone number of a colleague who will be providing coverage for me.


Privacy laws protect all communications between a client and a psychotherapist. In most situations I can provide information about your treatment to another party only if you sign a written release naming the party with whom you authorize me to exchange information, the purpose for the release of information, and a timeframe within which the authorization is effective.
A few situations require only that you provide advance consent in writing for general releases of information. Your signature on this client consent form authorizes me to release information about your treatment as follows:

  • Consultations with other health and mental health professionals about a client or a matter. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals also are legally obligated to keep the information confidential. I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your clinical record.
  • Formal business associate contracts with individuals who perform administrative functions for my practice. I share protected health information with these individuals for marketing, data collection, scheduling and billing purposes. All independent contractors have been given training about protecting clients’ privacy and have specifically agreed not to release any information except as specifically allowed in the contract or otherwise required by law.
  • Disclosures required by health insurers or to collect overdue fees. (These disclosures are discussed elsewhere in this agreement.)

Some situations, described below, allow or require me to disclose information without your consent.

  • If you are involved in litigation and the court were to order me to disclose information about the psychotherapy services that I provide to you, I must comply with the order.
  • If a government agency requests information for health oversight activities, I must provide it.
  • If you were to file a complaint or legal action against me, I may disclose relevant information to defend myself.
  • If you were to threaten to harm yourself, I may be obligated to seek your hospitalization or to contact others who can help to provide you with protection.
  • If you were to file a worker’s compensation claim, and I receive a request from your employer, the worker’s compensation insurance carrier, or the Labor Commission, I must provide the relevant information.

In certain situations, set forth below, the law requires that I reveal information about a client’s treatment if I believe that it may be necessary to protect others from harm. These situations are unusual in my practice.

  • Child abuse. If I have reason to believe that a child has been or may be subjected to abuse or neglect, state law mandates that I immediately notify the Division of Child and Family Services or an appropriate law enforcement agency. Once such a report is filed, state agencies may require me to provide additional information.
  • Abuse of a vulnerable adult. If I have reason to believe that an elderly or incapacitated adult has been or may be subjected to abuse or neglect, state law mandates that I immediately notify Adult Protective Services or an appropriate law enforcement agency. Once such a report is filed, state agencies may require me to provide additional information.
  • Threat of harm to another. If you were to communicate an actual threat of physical violence against an identifiable victim, I am required to take protective actions, including notifying the potential victim, contacting the appropriate law enforcement agency, and/ or seeking your hospitalization.
  • Communicable disease. If I have reason to believe that you are suspected of having or suffering from a communicable disease, I am required by state law to report this information to the state Department of Health.

Professional Records

I maintain two types of client records. Your clinical record contains information such as treatment plans sent to insurance companies and progress notes, along with records of consultations and signed releases of information. This record is available for your review in my presence or in the presence of another professional. The other record contains my psychotherapy notes. These notes are for my own use. They are not available to you or to anyone else without your written, signed authorization.

Insurance Reimbursement

If you have health insurance, it will provide coverage for mental health treatment. You are responsible to determine the mental health benefits that your health insurance policy provides and you will be responsible for knowing and complying with your insurer’s requirements for coverage. If I have a contractual relationship with your insurer (meaning that I am “in-network” or a “preferred provider,”) I will charge you for a copayment or coinsurance amount and will bill the insurer for the balance. If I do not have such a contractual relationship, I will provide you with invoices reflecting all of the information required to assist you to receive the benefits to which you are entitled. You, however—not your insurer—are responsible for the full payment of my fees.

You also should be aware that your contract with your insurer requires that I provide it with information relevant to the services I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release the minimum amount necessary for the purpose requested. I will provide you with a copy of any report I submit upon your request. By signing this consent, you authorize me to provide requested information to your insurer.

Billing and Payments

I require payment at the time of service. I accept cash and credit card payments. For my protection, I require that you provide me (through my accountant) with credit card information and authorization to charge your card for the balance due. Based on your preference, I can take responsibility to charge the balance due on your card on a regular basis or only if you have a balance due upon termination of the therapy process. By signing this consent, you authorize me to charge your credit card for the balance due on your account.

If your account is unpaid for more than 60 days from the date of service, arrangements for payment have not been agreed upon, and your credit card is declined, I will charge interest of 1.5% per month on any balance. In such a case, I also will have the option to use legal means to secure payment. Under these circumstances, I may be required to disclose otherwise confidential information necessary pursue to the claim to a collection agency or small claims court. If I am compelled to take legal action, you will be expected to pay a collection fee of 50% of the amount due, plus any attorneys’ fees, and court costs.