Intake & Required Documentation

Before scheduling with a clinician, the following forms must be completed in the client portal:

• Notice of Privacy Practices (HIPAA)
• Informed Consent for Psychotherapy
• Practice Policies
• Payment & Cancellation Policies
• Demographic Information & Credit Card Authorization
• Self-Pay Election Form (if applicable)

Required Items to Remain an Active Client

• A current insurance card (front and back)
• Valid photo ID
• Working credit or debit card on file
• Current mailing address and phone number

Note: Failure to maintain updated documentation may delay scheduling or result in temporary suspension of services.

Payment Policy

Credit Card on File

A valid credit or debit card is required to remain on file. The card will be charged before each session for the applicable session fee, copay, coinsurance, deductible, or self-pay rate.

If the card is declined, I will make one manual attempt to process payment during the session. If payment is still unsuccessful, the session may be shortened or rescheduled. Repeated declined payments may result in suspension of services until the balance is resolved.

Session Fees

• Standard self-pay fee: $155 per session
• Fees are subject to change with advance notice
• Fees may increase by up to 10% annually to reflect rising operational costs
• This fee also applies to late cancellations and missed appointments, as insurance does not cover these charges (Medicaid clients with active policies are exempt from this policy)

Insurance, Denials, and Client Responsibility

If you choose to use insurance:

• Insurance is a contract between you and your insurance company
• Good Faith Estimates are provided when required but are not guarantees
• You are responsible for understanding your plan's deductible, copay, coinsurance, and coverage limitations

If a claim is denied due to:

• Incorrect or outdated insurance information
• Inactive or terminated plans
• Undisclosed secondary insurance
• Non-covered services
• Exceeding plan limits

You are responsible for the self-pay session fee. You will be notified of the denial before your card is charged.

Superbills

Available upon request. You are responsible for submitting them to your insurer.

Cancellation and No-Show Policy

24-Hour Cancellation Requirement

To avoid a late cancellation fee, appointments must be cancelled or rescheduled more than 24 hours in advance.

Late Cancellations & No-Shows

A $155 fee applies to appointments missed or cancelled with less than 24 hours' notice. Insurance does not cover these fees. (Medicaid clients with active policies are exempt.)

Repeated Missed Appointments

Repeated late cancellations or no-shows may result in:

• Loss of recurring appointment times
• Suspension of future scheduling
• Termination of services

Clients will receive written or electronic notice before termination.

Unpaid Balances & Collections

Balances unpaid for more than 90 days, without an approved payment arrangement, may be sent to collections. Collection-related legal or administrative fees may be added to the balance.

If sent to collections, only the following will be disclosed:

• Your name
• The nature of services (e.g., "mental health services")
• The amount owed

This practice complies with HIPAA minimum necessary disclosure standards.

Recording Policy

Recording of sessions, phone calls, or consultations—whether audio or video—is strictly prohibited unless both parties provide explicit written consent.

Unauthorized recording may result in:

• Termination of services
• Refusal of future scheduling

This policy protects client confidentiality, therapist privacy, and the integrity of the therapeutic relationship.

Location Requirement for Services (Virginia Law)

All clients must be physically located in the state of Virginia at the time of each session, including telehealth services. This is required under Virginia licensure laws governing behavioral health professionals.

Clients will be asked to verbally confirm their physical location at the start of telehealth sessions.

Client Responsibilities Summary

By receiving services, you acknowledge that:

• All required intake documents must be completed before the appointment time and date
• You must maintain current insurance information, ID, and address
• A working credit or debit card must remain on file
• You are financially responsible for fees not covered by insurance
• You must inform the practice if you have multiple insurance plans
• You understand that Good Faith Estimates are not guarantees
• You are responsible for knowing your insurance benefits and notifying the practice of any changes
• Late cancellations and no-shows incur a $155 fee (Medicaid clients with active policies are exempt)
• Fees may increase annually by up to 10%
• Unauthorized recording is prohibited
• You must be physically located in Virginia for all sessions
• Services may be suspended for unpaid balances, declined payments, or missing documentation