R&A Therapeutic Partners
5901 SW 74 Street, Suite 201
South Miami, Florida 33143
PSYCHOTHERAPIST/CONSULTANT - CLIENT SERVICES AGREEMENT
I would like to welcome you to my practice! This agreement contains important information about my professional
services and business practices. It also contains information about the Health Insurance Portability and
Accountability Act (HIPPA), a new federal law that provides new privacy protections and new patient rights with
regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment,
payment and health care operations. HIPPA requires that I provide you with a Notice of Privacy Practices (for use
and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPPA and its
application to your personal health information in greater detail. The law requires that I obtain your signature
acknowledging that I have provided you with this information at the end of the session. Although these documents are
long and complex, it is very important that you read them carefully before you sign them. We can discuss any
questions you may have during our session. When you sign this document you are entering into an agreement with me.
You may revoke this agreement at any time!
I normally conduct an evaluation that will last from 1-2 sessions. By the end of the evaluation, I will be able to
offer you some impressions of what our work will include and a treatment plan to follow, if you decide to continue
with therapy. If you have any questions about my procedures, we should discuss them as they arise. If your doubts
persist, I will be happy to refer you to another mental health professional so you may get a second opinion.
Once I have completed my evaluation and made recommendations for treatment, we can both decide if I am the best
person to provide the services that you need to meet your treatment goals. If you agree that we will work together,
I will usually schedule sessions of 50 minutes each (one appointment hour of 50 minutes, with 10 minutes allotted
for record keeping) at a time we can both agree on. Once an appointment is scheduled, you will be expected
to pay for it unless you provide at least 24 hours notice of cancellation.
My hourly rate is $225 for all individual and family psychotherapy
appointments. I expect payment to be made at the time of service. You may pay me by
in advance for a number of sessions, if you wish. Most sessions will last only 50 minutes however initial
sessions may take up to 90 minutes. These sessions will be charged at $350 and will
interpretation of any testing results and consultation with other professionals, as needed. Additionally, I
$225 per hour for other services including report writing, telephone conversations lasting
longer than 10 minutes, consulting with other professionals with your permission, preparation of records or
treatment summaries, and the time spent performing any other service you request of me. These services will be
broken down by my hourly rate and charged accordingly. I also offer some customized
programs that are billed differently so if I make a recommendation for one of these programs, I will provide a
separate description of your individualized program and the associated fees.
Intervention/Therapeutic Placement Services
In some cases, an individual may need intervention or placement in a therapeutic program or school. I do provide
intervention/placement services for adults and therapeutic consulting services for teens and young adults.
Intervention and placement services will include intervention preparation and execution, assessment,
testing if necessary (provided at additional fee by a consulting psychologist), research to match individual to
appropriate program, coordinating admission with program and providing clinical information, as well as
services with programs while the person remains in treatment. In addition, I will provide support to family
individual is receiving treatment and I will coordinate aftercare plans for the patient once discharged. I have
separate contract, which outlines these services and details the charges for an intervention/placement or other
therapeutic consulting service. A typical consultation for intervention/placement is
$350 per hour and
will be collected prior to the session being confirmed.
I am often not immediately available by telephone. While I am usually in my office, I may be in session with
client. When I am unavailable my telephone will be answered by voicemail, which I monitor frequently. I will
every effort to return your phone call the same day I receive it, with the exception of weekends, holidays and
scheduled vacations. If you have an emergency and are unable to reach me you should:
- Contact your physician or psychiatrist
- Contact the nearest hospital emergency room
- Contact the Switchboard of Miami at 305-358-4357
- Contact Jackson Memorial Hospital 305-585-6487
- Contact Miami Children’s Hospital Dept. of Psychiatry at 305-666-6511
If I will be unavailable for an extended time, I will provide you with the name of a colleague for you to
Text Message Communication: Whenever possible, our communication
occur through face-to-face meetings, by phone or email. I will accept text messages as a brief form of
to arrange appointment times, coordinate logistics, ask a simple, non-consequential question or in case of an
emergency when you need to reach me immediately. I will not discuss recommendations, provide therapeutic
otherwise engage in substantive exchanges via text message. I ask that you please reach out to me by phone or
whenever possible rather than via text message. Please understand that text messaging is not an acceptable form
communication when it comes to therapeutic issues or situations that involve complex advice or consultation.
please be aware that if you send me a text message, I may not get back to you right away if I am in session, it
after hours or on the weekend or I am otherwise occupied.
Limits on Confidentiality
The law protects the privacy of all communication between a patient and a psychotherapist. In most situations, I
only release information about your treatment to others if you sign a written authorization form. Authorization
meet certain legal requirements as imposed by HIPAA. There are other situations that require only that you
written, advance consent.
There are some situations in which I am legally obligated to disclose information about you in the event that I
someone is in danger and I must take action to protect them from harm. These situations are unusual in my
however I must inform you of their possibility:
- If I know, or have reason to suspect that a child under 18 is abused, abandoned, or neglected by a parent,
legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires
that I file a report with the Department of Children and Family Services. Once such a report is filed, I may
be required to provide additional information.
- If I know or have reasonable cause to suspect that a vulnerable adult has been is being abused, neglected,
exploited, the law requires that I file a report with the central abuse hotline. Once such a report is filed
I may be required to provide additional information.
If I believe that there is a clear and immediate probability of physical harm to the patient, to
other individuals, or to society, I may be required to disclose information to take protective
action, including communicating the information to the potential victim, and/or the appropriate
family member, and/or the police or seeking hospitalization of the patient.