Statement of Policies and Informed Consent Form

Thank you for the opportunity to serve you. The following information is important in helping you to make informed decisions regarding my services. Please ask me questions at any time.

BENEFITS AND RISKS OF THERAPY: Some of the benefits of psychotherapy include relief from distressing symptoms, improved emotional health, new approaches to problem solving and decision making, more satisfying interpersonal relationships, increased levels of creativity, maturity and intimacy, as well as improved physical health. The greatest risk of psychotherapy is that it may not, by itself, resolve your problem or concern. I will assess progress on a session by session basis, but your active participation in this process is essential.

FEES: My fee is $150 per hour for individual therapy. Extenuating circumstances for a sliding scale fee may be considered. Payment is expected at the time of services unless we have agreed upon alternative arrangements or unless you were referred by your insurance company, in which case the co-pay is expected at the time of services. Should your insurance company refuse to pay for any reason, as the client, you maintain final responsibility for payment of fees. Please inform me of any special financial consideration or need you may have.

SCHEDULING APPOINTMENTS: (Please read carefully) Sessions are 50 minutes long unless otherwise arranged. If you arrive late for an appointment, the time will not be extended and you will be expected to honor payment for the full session. If I am responsible for a late beginning, I will guarantee a full session. If you miss an appointment or cancel without a minimum of 24 hours’ notice, you are responsible for payment of $75.

CLIENT RIGHTS AND CONFIDENTIALITY: You are entitled to receive appropriate care, respect, and confidentiality. I will hold all information confidentially unless you grant permission for me to share information by using a Release of Information Form. The laws of the state of Texas require that confidentiality may be breached: 1) when abuse of a child or elder has not been reported, in which case I will report it; 2) when I believe that there is danger of imminent harm to yourself or another; or 3) when a client reports unethical behavior by another therapist. Like many therapists, I seek consultation from other therapists to ensure the highest quality of services to you and to facilitate my own professional growth. In consultation I do not share specific identifying information.

TERMINATION OF SERVICES: Termination of services may be initiated by either of us. I sincerely request and advise that if you choose to terminate, we meet for a final “closure” session. Participating together in the ending process is an opportunity for a constructive evaluation and integration of the work we have undergone.

PROBLEM RESOLUTION: If you have a concern or problem regarding therapy that you or you and I as your therapist are not able to work out, you may wish to contact the Texas State Board of Professional Counselors at (512) 834-6658.

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Glenda L. Rice, MA, LPC
Psychotherapy and Consultation

713-664-5513 • 866-888-6283 (fax)