OFFICE POLICY STATEMENT
Please read this statement carefully and sign the Statement of Understanding on the bottom of this page.
CONFIDENTIALITY: Issues discussed during the course of psychological evaluation or therapies are confidential. No information will be released to anyone without written consent by the patient and if a minor, by the legal guardian of the patient. It is important to understand that the release of confidential information with or without consent is required in situations of potential harm to oneself or others, in instances where the court may subpoena records, and in cases of suspected child abuse. Whenever possible, you will be notified of this. The laws of the State of Florida require mental health professionals (in addition to other professionals) to report suspected cases of abuse (physical and/or sexual) and neglect to the Department of Children and Families.
FEES: Payment in full is expected at the time of each in-office visit. Skype and Phone appointments are to be paid in full when scheduling the appointment on line. Check, PayPal, electronic transfers accepted. No Credit Cards. There will be a $25 service charge for returned checks.
FORENSIC FEE: Note that, if your therapist must be involved in litigation because of the professional services that are provided to you: (1) She/he must be paid a forensic fee, which will be different from the regular in-office fee; (2) a retainer must be paid in advance, which will be based on an estimate of the minimum time that will be required for the services; and (3) out-of-office services will be charged on a portal-to-portal basis. The forensic fee will be applied to all services connected to the litigation, including but not limited to telephone conversations, electronic correspondence, depositions, and court appearances.
CANCELLATONS AND MISSED APPOINTENTS: Twenty-four (24) hour notice is required for all appointments. Failure to keep a scheduled appointment or failure to cancel an appointment 24 hours in advance will result in a charge of $100.00.
EMERGENCIES: If you have a true medical emergency, dial 911.
TELEPHONE CALLS AND ELECTRONIC MESSAGES: If you need to speak to Dr. Demner or send her a note in between sessions, there will be no charge for a brief 5-10 minute exchange. Any time beyond 10 minutes will be billed at a percentage of the normal 50 minute session. If you are at a point in your therapy that requires more frequent contact than was originally arranged, please discuss with your therapist about arranging for additional sessions.
ETHICS AND PROFESSIONAL STANDARDS: Your therapist is committed to uphold the most responsible ethical and professional standards possible and is accountable to you. If you have any questions or concerns about your course of treatment, please discuss these issues with you therapist. In signing this contract you are agreeing that should you have any dissatisfaction(s) or concern(s) about your evaluation and/or treatment, or should you wish to contact another mental health professional for services, that you will do your best to indicate that you are making a change and why you wish the change to be made. If you are unhappy with your services here and need help finding additional or alternative assistance, the therapist will do his/her best to help you locate a more suitable referral or mental health resource.
If, during the course of therapy you have any questions about the nature of your therapy (goals, procedures, etc.) or about your billing statement, feel free to ask.
STATEMENT OF UNDERSTANDING: If you have any questions, please ask before signing this form. Your signature indicates that you have read the Office Policy Statement and agree to enter the psychological evaluation and/or therapy under these conditions.
I HAVE READ THE OFFICE POLICY STATEMENT AND AGREE TO ABIDE BY ITS TERMS
______________________________ _______________________________________ ________________
Patient’s Name Signature of Patient/Guardian/Guarantor Date
Please read this statement carefully and sign the Statement of Understanding on the bottom of this page.
CONFIDENTIALITY: Issues discussed during the course of psychological evaluation or therapies are confidential. No information will be released to anyone without written consent by the patient and if a minor, by the legal guardian of the patient. It is important to understand that the release of confidential information with or without consent is required in situations of potential harm to oneself or others, in instances where the court may subpoena records, and in cases of suspected child abuse. Whenever possible, you will be notified of this. The laws of the State of Florida require mental health professionals (in addition to other professionals) to report suspected cases of abuse (physical and/or sexual) and neglect to the Department of Children and Families.
FEES: Payment in full is expected at the time of each in-office visit. Skype and Phone appointments are to be paid in full when scheduling the appointment on line. Check, PayPal, electronic transfers accepted. No Credit Cards. There will be a $25 service charge for returned checks.
FORENSIC FEE: Note that, if your therapist must be involved in litigation because of the professional services that are provided to you: (1) She/he must be paid a forensic fee, which will be different from the regular in-office fee; (2) a retainer must be paid in advance, which will be based on an estimate of the minimum time that will be required for the services; and (3) out-of-office services will be charged on a portal-to-portal basis. The forensic fee will be applied to all services connected to the litigation, including but not limited to telephone conversations, electronic correspondence, depositions, and court appearances.
CANCELLATONS AND MISSED APPOINTENTS: Twenty-four (24) hour notice is required for all appointments. Failure to keep a scheduled appointment or failure to cancel an appointment 24 hours in advance will result in a charge of $100.00.
EMERGENCIES: If you have a true medical emergency, dial 911.
TELEPHONE CALLS AND ELECTRONIC MESSAGES: If you need to speak to Dr. Demner or send her a note in between sessions, there will be no charge for a brief 5-10 minute exchange. Any time beyond 10 minutes will be billed at a percentage of the normal 50 minute session. If you are at a point in your therapy that requires more frequent contact than was originally arranged, please discuss with your therapist about arranging for additional sessions.
ETHICS AND PROFESSIONAL STANDARDS: Your therapist is committed to uphold the most responsible ethical and professional standards possible and is accountable to you. If you have any questions or concerns about your course of treatment, please discuss these issues with you therapist. In signing this contract you are agreeing that should you have any dissatisfaction(s) or concern(s) about your evaluation and/or treatment, or should you wish to contact another mental health professional for services, that you will do your best to indicate that you are making a change and why you wish the change to be made. If you are unhappy with your services here and need help finding additional or alternative assistance, the therapist will do his/her best to help you locate a more suitable referral or mental health resource.
If, during the course of therapy you have any questions about the nature of your therapy (goals, procedures, etc.) or about your billing statement, feel free to ask.
STATEMENT OF UNDERSTANDING: If you have any questions, please ask before signing this form. Your signature indicates that you have read the Office Policy Statement and agree to enter the psychological evaluation and/or therapy under these conditions.
I HAVE READ THE OFFICE POLICY STATEMENT AND AGREE TO ABIDE BY ITS TERMS
______________________________ _______________________________________ ________________
Patient’s Name Signature of Patient/Guardian/Guarantor Date