Welcome to my practice! I’m so glad you’re here and look forward to working together. Thanks for taking the time to review this and make sure we’re on the same page about the details. It’s important information and a legal agreement, so please make sure you understand everything and ask any questions you might have before signing.
This is likely obvious, but “I” refers to InnerWell LLC and Therapist Rachel Zamore, and “you” refers to the Client.
Format
Sessions take place online via secure videoconference (“telehealth”), unless other arrangements have been made. Should we get disconnected during a video call and unable to reconnect in a timely way (or if the connection is inadequate), I will call you to continue the session by phone.
Please be sure to have a strong internet connection prior to the start of our meetings, and it is recommended to close extra browser tabs and applications to maximize bandwidth. Similarly, I suggest disabling reminders and pop-ups, etc, to minimize distraction. Please take whatever steps are needed to ensure that you will have privacy while we are in session and to minimize the likelihood of interruptions.
Scheduling
The day and time we choose to meet will be held for you as a recurring weekly appointment unless we have made other arrangements, confirmed in our email communications. I ask that you provide as much notice as possible for any planned absences (one week minimum), and I will do the same for you whenever possible.
If you are regularly unable to meet at our agreed-upon time, we may need to shift to a floating appointment that we schedule a few weeks out at a time.
Throughout the year I will take planned time off from my work for personal vacations as well as for professional training and occasionally teaching. You will be given advanced notice of any pause in sessions or change in schedule, and together we will make arrangements for continuity of care if that would feel helpful. While infrequent, there may be times were we go several weeks without meeting. If you anticipate this being challenging, please discuss early in our work together so we can assess whether we are a good match.
Fees
Payment will be charged to a card on file at the time of service, if not previously paid for at the time of scheduling. By signing this agreement, Client authorizes InnerWell LLC to process your card on file for all legitimate fees incurred as outlined in this agreement.
Client agrees to provide timely updates on payment method if needed, and understands that full payment is due at or before the time of service.
Extra services provided upon request are charged at the same rate as clinical services, prorated to the nearest quarter-hour. Examples include (but are not limited to) document review, report writing, additional requested session time, Client phone calls or email communications lasting longer than 10 minutes, and collaborative care meetings with other providers you might want me to speak with.
Fees may increase on an annual or biennial basis, and you will receive at least 2 months’ notice in the event of a fee change.
I will only participate in legal proceedings when legally required to do so, and any services, involvement or travel time related to legal proceedings is charged at a rate of $150.00 per quarter hour.
Insurance
Please note that I am not an in-network provider with any insurance company, nor do I or InnerWell provide billing services. Clients who wish to self-submit for potential possible insurance reimbursement will be provided with a monthly superbill itemizing services provided and fees paid. Insurance will require that a diagnosis be included.
All fees are due in full at the time of service and any reimbursement would be entirely between you and your insurance company. If this is important to you, please be sure to confirm your benefits, deductible, and coverage so you can make an informed decision.
Any requested documentation or administrative work related to insurance communications (beyond provision of superbills) will be charged to the Client at the same rate as clinical services.
Rescheduling of Sessions
Forty-eight (48) hours’ notice by email to rachel@innerwell.org is required to reschedule or to cancel an appointment otherwise full payment is due (and will be charged to the card on file).
Rescheduling within the 48-hour cancellation window is considered to be the same as scheduling an additional appointment and full fee will be due for the new appointment in addition to the charge for the late-cancelled appointment. In the event of a truly unforeseeable emergency situation resulting in a late cancellation, a no-charge reschedule within the same calendar week may be possible.
Social Media
In order to protect your privacy and mine, I do not accept connection requests from current or recently former clients on social media. If you choose to engage in anything I share online publicly, I will not acknowledge you as a client in order to protect the confidentiality of our relationship. The same is true should our paths cross in real life.
Closure
Either party may choose to end this relationship at any time. Ideally, this will be done with plenty of advance notice (1 month or more is recommended) as clients generally gain maximum benefit from having an intentional process of consolidation and closure. I highly recommend at least one final face-to-face meeting. Regardless of the length of notice provided, any outstanding fees must be paid and late cancellation notice applies for any remaining scheduled sessions.
Confidentiality
Your right to confidentiality is protected by Federal and State law. Information about you and which you disclose in session will not be repeated without your written consent except in the following situations:
- If you are a danger to yourself, others, or the property of others I am required by law to take measures to protect the safety of all involved.
- I am required by law to report cases of abuse or suspected abuse of children, the elderly or disabled or vulnerable individuals to the appropriate state authorities.
- I may be required to divulge information and records by court order. This usually occurs in situations involving the need for hospitalization, child custody, or personal injury lawsuits.
- To insure the highest standards of care mental health professionals occasionally consult with or receive supervision from colleagues. During such consultations and supervision care is taken to protect the identity of the Client.
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By signing this Agreement, Client agrees to its terms and acknowledges that he or she has read and understands the Privacy Policies and has had the opportunity to review Rachel’s practice philosophy, training, and experience.
