Therapy Agreement & Consent to Services

Services

1. Your engagement in services with Pennsylvania Holistic Healing, LLC is completely voluntary. You are free to make the choice to stop services at any time, though we encourage you to speak to your therapist about this prior to disengaging from services.
2. Therapy can at times evoke uncomfortable emotions as clients process difficult thoughts, feelings, experiences, relationships, and perceptions of self. Your work in therapy may at times be challenging as you work toward your goals. Therapy has been shown to be effective in reducing experiences of distress, increasing satisfaction in various aspects of life, increasing one’s ability to cope with life stressors, and find a pathway to a more value-aligned life. There are no guarantees made about the outcome of your work with your therapist at Pennsylvania Holistic Healing, LLC.
3. Over the course of your treatment it may become apparent to your therapist that a different type or intensity of treatment is better suited to meet your needs. Pennsylvania Holistic Healing, LLC strives to deliver quality care within our scope of practice, and at times that means your therapist may make a referral for something they are not able to provide to you.
4. Your Pennsylvania Holistic Healing, LLC therapist, in efforts to assure quality and appropriately matched care, will engage in ongoing assessment of how the therapy modalities and approaches provided are meeting your individual needs. We encourage you to do the same and discuss any concerns with your therapist.
5. All services and interactions adhere to Ethical Guidelines as outlined by the American Psychological Association, the American Counseling Association, and HIPAA requirements. Our art therapists are also governed by the Art Therapy Credentials Board.

Payment

1. Pennsylvania Holistic Healing, LLC does not currently participate in network with any insurance providers. We are happy to provide you with a Super Bill you can submit to your insurance company for reimbursement, but we are unable to guarantee that you will receive reimbursement from your insurance carrier.
2. Payment is due at time of service, and Pennsylvania Holistic Healing, LLC accepts cash, check, and credit or debit cards (for telehealth sessions we ONLY accept credit/debit/ACH bank transfer/HSA/FSA at this time).
3. Invoices for telehealth services will be sent to clients and are to be paid upon receipt.
4. If two sessions go unpaid, additional sessions will not be scheduled until your balance is paid in full.
5. Clients discharged with an unpaid balance will be referred to another provider should they seek services with Pennsylvania Holistic Healing, LLC in the future.
6. While at times clients receiving services may have agreements with others (i.e. family, significant other, friend, support person, etc.) for payment for services, the ultimate payment responsibility falls on the client. For this reason, any unpaid balances are the responsibility of the client.
7. Pennsylvania Holistic Healing, LLC reserves the right to release any information required to obtain payment, dispute chargebacks, and resolve payment discrepancies.
   
   

Fees

An initial 15 minute phone Consultation is offered free of charge.

Individual and family sessions (50 minutes) cost $100.

We do have a limited number of reduced rate appointment slots available for those who meet our criteria. Please let us know if you are experiencing a financial hardship and we will explore payment options with you.

Other Professional Services will be charged at the hourly standard session rate of $100/hour ($1.66/minute), prorated for the amount of time the task requires (example: 25 minutes = $41.50). Other Profession Services include:

1. letter writing, compilation of records, developing treatment summaries
2. attendance at meetings or consultations you have requested
3. telephone calls lasting more than 15 minutes
4. any other service requested by you outside of the typical therapy services provided

Court Appearances

If your therapist is subpoenaed to appear in court on your behalf you will be charged $1,500 per day
plus travel expenses. If your therapist’s participation in your court hearing is compelled by another party, every effort will be made to obtain payment from the compelling party. Any amount not paid for by the compelling party will be the responsibility of the client.

It is important that you are aware that while a therapist may be subpoenaed for appearance on a certain day, they are not always asked to testify or participate on that day or at all. This does not void the established fee for court appearances.

Travel expenses may include any or all of the following:

• Fuel (we will charge the current IRS mileage rate per mile at the time of subpoena).
• Airline accommodations where applicable, subject to the subpoenaed therapist’s discretion.
• Tolls.
• Lodging (in stances when we may be required to be present for multiple days, if the location of appearance is more than 100 miles round trip).

Attendance

1. We ask that should you need to cancel an appointment, please do so with at least 24 hours notice. Appointments that are cancelled with less than 24 hours notice will be billed as a “late cancel” at your full session rate.
2. If you do not show up to your scheduled appointment, and your therapist has not heard from you, you will be billed as a “no show” at your full session rate.
3. Please arrive on time to your scheduled session. If you are more than 15 minutes late to your scheduled session, your therapist reserves the right to reschedule your session. Under these circumstances you will be billed for the session as a “no show”. Please communicate with us if extraneous circumstances present a problem with your scheduled time.

Telehealth Considerations

1. It is imperative that you reserve dedicated therapy time in your schedule. If you are unable to present to your session ready to commit your full attention, your therapist reserves the right to reschedule your session. Under such circumstances you will be still be charged for the session. To avoid this, please make sure you have a private space to conduct telehealth sessions, and ensure a reliable internet connection. Continued difficulty ensuring a private space for therapy may result in your therapist providing you with alternative providers who may be conducting in person sessions if in person services are not available at Pennsylvania Holistic Healing, LLC.
2. Your therapist reserves the right to discontinue a session if you have not secured a private space, are driving, at the store, with friends, etc. You will be billed at your full session rate.
3. If you and your therapist are disconnected during a telehealth session, your therapist will attempt to reconnect twice. Failure to re-connect to telehealth session will signify the conclusion of the session and you will still be charged the full session rate.