Resolution Counseling Center: Our 4 New Client Agreements
Please read these 4 short agreements before your first session and initial and sign below to indicate your agreement. If we have not receive your agreements before your first session, your therapist will take the first few minutes to help you get it signed. If you do NOT agree please contact our office to discuss your options.
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Privacy Notice Agreement: I know that a copy of Resolution Counseling Center’s Notice of Privacy Practices is available on the RCC website (see Paperwork page) and I have been given an opportunity to read it. I understand that if I have questions regarding the notice or my privacy rights, I can contact Melissa Schneider, Practice Owner, at *
Communication Agreement: I agree that the email and phone number(s) I have provided are safe channels through which the center can contact me with detailed voicemails or emails. *
Agreement to Charge Fees to Card on File: I understand the RCC team has done their best to determine my copay/insurance-related session costs but that new information occasionally emerges after initial claims come back. I understand that RCC recommends I also confirm my out-of-pocket costs with my insurance provider before the first session. I agree that RCC can collect, via the card I've put on file, whatever cost-share my insurance determines to be my responsibility. Secondly, if I need to cancel my appointment on the same day, or if I do not show up for my appointment, I agree to pay a fee of $50 for a 50 min sessions or $100 for a 90 min session. I understand the fee will be charged to the card I have put on file. (Why is there a fee? We do not double-book our sessions and thus you are reserving a specific appointment time with your therapist. If you do not attend, your therapist does not get paid for the time you reserved. For this reason, nearly every therapy practice has a cancellation policy. With us, you can cancel up to the night before a scheduled session with no penalty.) *
Treatment Team Agreement: I understand that Resolution Counseling Center uses a treatment team approach to ensure the highest quality of care. Each therapist on the team (Danielle Fokshner, LAC, Max Laffend, LSW, Jaime Elliot, LAC, Terri Watkins, LAC, and Rosa Gomez, LMFT) participates in weekly case conferences led by our clinical supervisor Mr. Joel Levine, LCSW, LPC, LCADC, LMFT and/or practice owner Melissa Schneider, LCSW. I understand that my case information may be shared in these meetings so that I may benefit from the expertise of many clinicians as my therapist develops an effective plan for my treatment goals. *
I agree to electronically sign this form by writing my full name below *
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