Client Contract Form
To view and print this form in pdf, please click here.
When people start counseling they usually have a lot on their minds and do not always remember details about my office arrangements. Therefore, I am providing my policies in writing. I encourage you to take the time to read these through before you first appointment. Please feel free to bring up any questions you may have.
1. Fees : Please call for fee information.
2. Cancellations : Cancelled appointments 48 hours in advance will relieve you of any financial obligation for that time slot. Failure to cancel 48 hours in advance will result in your being billed the full fee of your scheduled session for individual and couples therapy. This time is scheduled only for you so that without notice someone else in need of an appointment time cannot fill it. If our schedules allow for another appointment in the same week, you will not be responsible for payment for that missed appointment. Insurance reimbursement does not cover missed appointments. Payment in full for the missed appointment is expected at the next appointment.
3. Payment for professional services is expected at the time of each individual/couple/group session. Checks can be made out to Joe Kort and given to me at the beginning of the session. You will then be given a receipt with the necessary information required to submit to your insurance company for reimbursement to you. There is no direct billing with any insurance company.
: Many of the costs of outpatient psychotherapy are covered by health insurance. Please check with your insurance company. There are a growing number of insurance companies and an assortment of different types of policies within these companies. It is crucial that you find out what your individual coverage is. These companies most often will only provide you with the information regarding your coverage not me as the professional providing
the services. Benefit information can be obtained either through your personnel office at work or directly from your insurance company.
The following guidelines will be helpful:
• Ask for details about your outpatient psychiatric/mental health coverage.
• Ask if they reimburse for outpatient psychotherapy from a certified social worker with a Master’s in Social work and certified with the state of Michigan not affiliated with a clinic working independently. I am a Master’s in Social Work (MSW), Licensed Social Worker (LMSW). The LMSW is for licensure. I am not affiliated with any insurance company nor any clinic.
• Ask if your policy has a requirement regarding licensure and degree (i.e. M.D., Ph.D., M.S.W, M.A. or does it require the clinician to be supervised by M.D. or Ph.D.).
• If they provide coverage for my services then ask how much it pays per visit, whether you have a maximum number of visits or maximum dollar amount per calendar year, how much your deductible is and if they will reimburse you as you are paying the therapist directly.
5. Termination: An orderly end of therapy has positive effects for clients. It is suggested that you discuss openly with me your wish to end therapy at least three sessions prior to your last session. A final closure session has proved to be very important for clients. Closure sessions help you acknowledge and summarize what you have accomplished and discuss any unfinished concerns you may have. While not required they are strongly recommended.
6. Notice of Privacy Practices (HIPPA) : By signing I acknowledge that I have read the NPP and am aware of how my medical records may be used and disclosed.
About Cancelled and Missed Appointments
I take missed appointments very seriously. I understand that things come up which are out of your control which prompt the need to cancel an appointment in less than 48 hours. This remains your responsibility to pay for your time. This time is scheduled only for you so that without notice someone else in need of an appointment time cannot fill it.
Cancelled appointments 48 hours in advance will relieve you of any financial obligation for that time slot. This can be done by sending a voicemail or email. If done by email you need to have confirmation from me stating that I have received it.
Failure to cancel 48 hours in advance will result in your being billed the full fee of your scheduled session for individual and couples therapy.
If our schedules allow for another appointment in the same week, you will not be responsible for payment for that missed appointment.
Insurance reimbursement does not cover missed appointments. Payment in full for the missed appointment is expected at the next appointment.
I am willing to have a telephone session with you if you are unable to make it into the office for an appointment so that you can still receive my services.
As your therapist, I consider any feelings and thoughts you have about being charged for a missed appointment as therapeutic and invite you to discuss them with me.