Informed Consent

Hello! Welcome to Deeds Counseling. This document is a legal agreement. It’s purpose is to inform you about my policies and procedures and set boundaries for our relationship.


Boundaries define the limits of a relationship by explaining what behavior is expected and what is not expected. It is important to set boundaries early in any relationship and not wait until a boundary is crossed. Because the counseling relationship is a supportive and caring relationship, people can mistake it for a friendship. Counseling is a professional, business relationship, not a friendship. Friendship would confuse the counseling relationship.

Boundaries define the limits of a relationship by explaining what behavior is expected and what is not expected.

Risks and Benefits

There are risks and benefits to counseling. Counseling can bring unpleasant memories to your awareness. You may face uncomfortable feelings. Progress is not guaranteed and can happen slowly. To get the most benefit, it takes hard work both in session and between sessions.

However, there are many benefits to counseling. Your counselor can help you develop coping skills, learn stress or anger management skills, improve your communication and social skills, make behavioral changes or define goals and objectives. Your symptoms or the quality of your life may improve. You may become more motivated and productive.

The Therapeutic Process

The therapeutic process begins when you call for your first appointment. The intake process is the next step. It’s important for you to take some time to complete your intake. The information you provide will help me find the appropriate treatment for you.

After the intake, you’ll work on a treatment plan. Your treatment plan will define your goals and will be the focus of your treatment. You will work on treatment plan goals between sessions. During sessions, we will review your progress and work on motivation and skill building, as needed.

Treatment Planning

Treatment plans are the framework for counseling sessions. They decide what we will focus on and talk about each week. A treatment plan includes goals and objectives. Goals are the long-term changes you want to make. Objectives are the steps you need to take to reach your goals. Goals and objectives need to be specific and measurable so we can track your progress.

Periodically, we will review your treatment plan and make any needed changes. If you are not making progress, we may need to adjust your goals or objectives. If you don’t make any progress after a time, I may suggest referring you to another provider. This is not meant to punish you but to help you find someone who will be more effective in meeting your needs.


Appointments are 45 to 60 minutes in duration, once per week at a scheduled time. I may suggest more or less sessions depending on your symptoms and/or disorder. Please try to schedule your appointment for the same time each week. Regular appointments make it easier to remember.

The time scheduled for your appointment is set aside just for you. If you need to cancel or reschedule, please give me 24 hours’ notice. This time is needed so I can adjust my schedule. Please be mindful that another client may be waiting for a time slot to open.

All clients must contact me the day before if an appointment needs to be cancelled or rescheduled.

Missed or Late Cancellation Discharge

It is my policy to discharge clients after 2 appointments are missed or cancelled without 24 hours’ notice. Please understand my time is limited and many people want an appointment. This policy assures all clients have the opportunity to schedule. If you are discharged under these circumstances, you can return to counseling after a 6 month period.

Clients will be discharged after 2 appointments are missed or cancelled without 24 hours’ notice.

Late Appointments

You are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. If you are more than 15 minutes late, I may not be able to see you because your session needs to be of sufficient length to be therapeutic. Some insurances also require a certain length for reimbursement. If I cannot be reimbursed because you were late, you will have to pay for the session.

Fees and Billing

You are responsible for paying on the day of your session unless other arrangements have been made with me. Payment can be made by insurance reimbursement, credit card, check or cash. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

Counseling Fees

My fees are $120 for a 60 minute session, $90 for a 45 minute session or $60 for a 30 minute session. Because of the more complicated nature of family and couples counseling, it is only offered in 60 minute sessions so it is $120. Group counseling, if available, is $60 for a 2 hour group. Intake is $120 if forms are completed online before your session. It is $150 if forms are not completed because forms can take an extra 30 to 45 minutes. Fees are not negotiable.

Court Hearing Fees

If you expect becoming involved in a court case, I recommend that you bring this up before the hearing. If your case requires my participation, you will be expected to pay for the professional time required at the rates listed above. Insurance does not pay for hearings.

Professional Letter Fees

Sometimes clients request letters to verify counseling, professional evaluations of progress or for other reasons. If you need a letter for any reason, you must complete and sign a consent before I can write a letter about your treatment.

If you need a simple letter verifying counseling, there is no charge for this. However, you must request the letter at the beginning of the session. Requests will be denied if you ask 5 or 10 minutes before the end of session. I need enough time so the session can end on time. Please be quiet while I am writing your letter. I can’t concentrate on 2 things at one time.

If you want a letter in between sessions, there is a charge for this. There is also a charge for letters that take extra time to write. An example is a professional evaluation of your progress for court. The fee for letters will be calculated using my professional fees listed in this document and according to the time involved. Insurance will NOT reimburse for this service. Payment is due before the letter is written.

You must request letters that verify counseling for your doctor at the beginning of the session and remain quiet while I prepare the letter.

Disability Form Fees

Social Security reimburses me for forms they send me to complete. If you want me to complete extra forms or write a letter for a disability claim, I charge according to my fees listed in this document and the time involved.

Late Cancellation Fee

If you cancel with less than 24 hours’ notice, you may have to pay for the session at the full rate your insurance reimburses. This fee may be waived one time at my discretion for an emergency. I reserve the right to decide what is an emergency. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. You will be responsible for the cancellation fee. Cancellation fees do not apply for clients with Medicaid insurance.

Paying with Insurance

When you use insurance to pay for treatment, you are responsible for knowing what your insurance covers. You are responsible for paying any co-insurance, co-pays and/or deductible. You are responsible for knowing if the provider you choose is in network with your plan. You are responsible for knowing if authorization is needed before your insurance will cover counseling.

Mental health benefits are often different from medical benefits. Please do not assume that your co-pay will be the same as it is for a doctor visit. It can take up to 45 days for billing to return once a claim is submitted. Until the claim is returned, I will not know how much your insurance will pay. You could be responsible for many sessions before the first claim is returned.

For all the reasons listed above, I strongly suggest you contact your insurance before your first session and ask how much counseling will cost.

I strongly suggest you contact your insurance before your first session and ask how much counseling will cost.

In order to bill your insurance, I must provide a clinical diagnosis. Sometimes I have to provide additional clinical information, which will become part of the insurance company files. By signing this Agreement, you are agreeing that I can provide requested information to your insurance carrier if you pay with insurance.

You may receive a bill from me when your insurance does not cover the full cost of a session. If you receive a bill, you can contact me with any questions. If you cannot pay the entire bill, you can request a payment plan.

If I am not a participating provider for your insurance plan, I can supply you with a special receipt called a superbill. You can submit the superbill to your insurance company for reimbursement. Not all insurance companies will reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

Contact Between Sessions

There may be times when you need to contact me between sessions. There are times when I charge for contact between sessions and many times when I do not.

Phone Calls

You will never be charged for crisis calls, an initial consultation, to schedule or reschedule appointments or to ask questions about billing matters or about what services are available.

If it is not a crisis and you call because you need to talk to someone, I do charge for this time. Charging for my time avoids boundary crossings by establishing that this is a professional relationship, not a friendship. Calls are charged by the quarter-hour according to the fee schedule above. Phone calls are not reimbursed by insurance at this time. If you are unsure whether a call is considered a crisis, just ask me. I will tell you if I will charge for the call.

Please be aware, I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible. However, it may take a day or two for non-urgent matters. If I don’t return your call after a couple of days, please call again. I can get busy and forget to return a call. I apologize for this in advance.

Text Messages

It is sometimes easier to reach me by text message than by phone. If you need to reschedule, let me know you are running a few minutes late or have another brief message, you can text me at 724-812-9895.

My Electronic Medical Record (EMR) will send a text message reminder of sessions to the mobile phone number I have on file for you. Most clients find the reminders helpful and appreciate getting them. However, you have the right to request to opt out of these text reminders. You can notify me at any time to change whether you get text reminders.

If you have a question about what you are supposed to work on between sessions or need a suggestion for how to manage a situation, feel free to contact me. I don’t charge for this as long as you don’t take advantage of my time. If you are texting excessively for suggestions, I will address this at your next session. You will be informed ahead of time if I intend to bill for this because you are contacting me excessively.


My Electronic Medical Record (EMR) can also send email reminders. If you do not want to get reminders by email, you can opt-out at any time by letting me know.

I may use email addresses to periodically check in with clients who have ended counseling suddenly. I may also use email addresses to send newsletters with valuable therapeutic information such as tips for depression or relaxation techniques. You always have the right to ask to be removed from these emails.

You can stop getting text or email reminders at any time by informing me.

After Hours Crisis

If you are in crisis, having suicidal or homicidal thoughts, please call me. It does not matter what time it is. You can call me at 3 in the morning if you think you might hurt yourself or someone else. In the event of a crisis, you can reach me at 724-812-9895.

I do not charge for these calls. I consider it a part of the fee I am paid for sessions. If I need to meet with you due to the severity of the situation, your insurance may cover this. I will bill your insurance if I am legally able to do so.

If you are in crisis, feeling suicidal or homicidal and you cannot reach me, go to your local hospital, call 911 or call a crisis hotline listed under crisis resources. Do not be afraid to ask for help when you need it. It could save your life.

Crisis Resources

If you have a crisis and cannot reach me, I have included other resources you can use. Chestnut Ridge has a crisis line that is available 24 hours a day, 7 days a week. They also have walk-in crisis intervention on weekdays and mobile crisis days and evenings until midnight. Chestnut Ridge has offices at 100 New Salem Road in Uniontown and 1051 Morrell Avenue in Connellsville. The Chestnut Ridge website has more information.

  • Chestnut Ridge Crisis Line 724-437-1003
  •  National Suicide Prevention Lifeline 1-800-273-8255
  • National Council on Alcoholism and Drug Dependence Hopeline 1-800-622-2255

Special Considerations for Clients on Medicaid

People are generally on Medicaid due to financial hardship. Because of their financial hardship, provider agreements with Medicaid do not allow charging clients for any services other than face-to-face contact. As a result, I cannot provide some services that your insurance does not cover. I cannot provide counseling via phone, online or other non-reimbursable services.

Special Considerations for Clients on Suboxone

You must request letters for your Suboxone doctor at the beginning of your session and remain quiet while I prepare your letter. I can’t concentrate on writing a letter and listen at the same time. You are responsible for reminding me when you need a letter. Do not assume I have sent your letter outside of sessions. I cannot provide letters for clients on Medicaid. Medicaid requires you to go to a licensed drug and alcohol facility, not private counseling.


Confidentiality means that what you tell a counselor is private. It will not be shared with your family, friends or other people. However, there are limits to confidentiality. There are some circumstances when I am required to release information and others when I am permitted to release information. This section describes these circumstances.

Under most circumstances, you must sign a consent form before information about your treatment will be released. The following are some examples of when you might want to sign a consent form.

  • You want your doctor, psychiatrist or another provider to know you are in counseling.
  • You want to bring a family member or spouse to counseling.
  • You want me to release information to Social Security related to a disability claim.
  • You want me to write a letter to probation or parole about your counseling.

Limits to Confidentiality

I am required by law to release information if:

  • You could hurt yourself or someone else.
  • A child or elderly person is being abused.
  • I receive a court order.
  • There is an emergency medical situation. In a medical emergency, I may release information that is necessary to prevent serious risk of bodily harm or death.

Confidentiality and Group Counseling

The nature of group counseling makes it difficult to maintain confidentiality. If you choose to participate in group counseling, be aware there is no guarantee that other group members will maintain your confidentiality. However, I will make every effort to maintain your confidentiality by reminding the group of the importance of not talking about the group outside of group. I will also remove any group member who violates the confidentiality rule.

Confidentiality and Technology

You may choose to use technology as a part of counseling. Technology includes but is not limited to video, telephone, email, text or chat. There is always the possibility that unauthorized persons may attempt to discover your personal information through the technology you use. I will take every precaution to safeguard your information but I cannot guarantee that unauthorized access to electronic communications could not occur.

Be careful that no one has access to your passwords, your computer, phone or other technology if you use it to contact me. Be aware of any friends, family members, significant others or even co-workers who may have access to your computer, phone or other technology used in your counseling. Take the time to delete any messages that contain personal information.


This Informed Consent may be periodically updated. I will have a copy available in my office and on my website at You can request a printed copy from me or print a copy from the website. This document was last updated on September 16, 2017.

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