Scheduling and Canceling Sessions

The client portal is my office assistant. If we are unable to schedule our next appointment at the end of the session, just log in here to see what's available.

In order to allow me time to do any necessary prep work for your session, or to handle emergency situations that come up with other clients, I ask that all sessions be scheduled at least 24 hours in advance.

PLEASE NOTE: One second after the clock turns to 24 hours before your session time, the system will NOT allow you to cancel your appointment. The button to cancel will disappear and you will not be able to make any changes. 

I ask that any changes such as cancellations, time changes, or changes in the lengths of the sessions be made 24 hours in advance. Sessions not canceled 24 hours in advance will be charged a $100.00 fee.

If you are running late, are sick, traveling, do not want to travel to the office in certain weather conditions, etc, we can always do a phone or video session at your scheduled time. Please text me as soon as you know that you will need to change your face to face session to one of these options.

I have read and I agree to the Scheduling and Canceling Sessions

Signature of Client or Legal Guardian                                                                 Date

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Payments

Payment is due at the time of the session. I will gladly file your insurance provided your insurance carrier is one that participates with me. If so, I will collect your co-payment at each session and file your insurance for you. If your insurance does not provide payment, you will be responsible for the bill. If no insurance is filed, you will be responsible for the bill at the end of each session.

You may pay online prior to the session, or at the end of the session. I am able to accept cash, checks, debit, credit cards, and health spending account cards (HSA).

*HSA cards can only be used in the office. The online system isn't an HSA approved processor.

I have read and I agree to the Payments

Signature of Client or Legal Guardian                                                       Date

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Limits of Confidentiality

The work we do together is sacred and is held in the utmost of respect and confidence.

These are the times when what we discuss may be shared with others:

1. If you bring a guest to one of our sessions, they will see, hear, and take part in our discussion. You may let me know if there are portions of our work you do not want shared in front of the guest.

2. If you ask me to share information with someone outside of our sessions, I will ask you to sign and return the "Release and Receipt of Information" form found here in the client portal. This will tell me who you want me to share information with, and what type to share. Examples of this are communicating with your doctor's office, a school, social services, etc.

3. If you need me to write a brief letter document to share with your school, employer, or other person. (You are asked to complete the "Release and Receipt of Information" form for this too. In addition, there is a brief letter document fee of $50.00 that applies. Should a longer document be requested, we will discuss any costs.)

4. If you use the invoices inside the client portal as "superbills" to send to your insurance company for reimbursement according to your plan, they will know that we work together and they will require that I give you a mental health diagnosis on your invoice.

5. If I suspect the abuse of children under the age of 18, of those who have disabilities, or the elderly, then I am required by law to contact the Department of Social Services.

6. If you are seriously contemplating harming yourself or someone else.

I have read and I agree to the Limits of Confidentiality

Signature of Client or Legal Guardian.                                                                             Date

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Legal and Court Proceedings

I am not deemed an expert witness through the court system, and I do not testify in court. 

I have read and understand Legal and Court Proceedings

Signature of Client or Legal Guardian                                                                             Date

Client Name:

Date/Time:

Please be sure that you have read over the "Welcome" document before completing this form. Then read over and complete this form carefully. Let me know if you have any questions about anything, and I'll be happy to answer them.

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1. I agree to pay the following rates for therapy services (same price applies for in-person, phone, or video sessions):

30 minute session: $125.00

50 minute session: $175.00

60 minute session: $175.00

75 minute session: $200.00

90 minute session :$225.00

2 hour session:$325.00

Initial intake/evaluation: $200.00

I understand that not all lengths of services are covered under insurance. If I choose a session longer than what my insurance allows, I am choosing to be responsible for the rate charged. 

Yes_____      No______

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2. Due to being in session and other meetings, I am unable to answer the phone due to confidentiality reasons while I'm with others. This is to protect your confidentiality so that others can not possibly overhear. Unless we have a scheduled time to talk via phone, I will more than likely not be able to answer any calls. 

All calls that share updates in your life, where you need guidance, or need help processing or figuring out how to proceed are considered therapeutic in nature and must be scheduled in advance through the client portal system. This helps me to make sure that I am in a safe, secure, confidential place, and that my mind is cleared from other tasks so I can give you my full attention. These calls are treated as sessions and do require payment.

Phone calls about billing, questions concerning policies, or other such topics are not considered therapeutic in nature. Often, these questions can be shared and answered during our sessions together or through mail sent through this client portal. Should you want to ask me about those things via a phone call, please send me a message in the client portal so we can schedule a time to talk. If the conversation veers towards a therapeutic topic, the session will be billed.

Yes______               No_______

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3. I understand that payment is required at the time of each session. Payment can be made by cash, check, credit/debit, or HSA card. I understand that if I am filing insurance, I am responsible for the copayment at the time of each session. I also understand that if insurance does not reimburse for my session(s), I am responsible for the payment.

Yes_____                 No_______

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4. I understand that should a check bounce, there will be a fee of $25.00, in addition to the fee for service.

Yes_____                 No_______

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5. I understand that if an appointment needs to be changed, adjusted, or canceled, that 24 hours notice be given in order to avoid a fee of $100.00.

The default is always a phone session at your scheduled time. Just give me a call then and we will conduct the session over the phone.

Yes_____                No______

Client Name:

Date/Time:

Read over and click the appropriate response to each of the following questions. Please let me know if you have and questions about anything, and I'll be happy to answer them.

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1. I/We have read and understand the fees for services, to include the session fees for 30, 50, 60, 75, 90 minute, and 2 hour sessions, phone and video sessions, and returned check fees.

Yes______                    No______

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2. I/We understand that Allison A. Brodeur, Ms, LMFT, PLLC is not an emergency service. In the event of an emergency, I/we can call 911, or REAL Crisis Center, depending upon the nature of the emergency at hand. REAL Crisis Center is a free, confidential, 24/7 service with trained crisis responders via 252-758-HELP (252-758-4357)

Yes______                    No_______

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3. I/We know that Allison A. Brodeur, MS, LMFT, PLLC does not give evaluations in matters of custody. 

She does not give intelligence and educational testing.

She does not give testing for jobs.

She does not evaluate animals for emotional support or service animals.

She does not prescribe medications (only physicians, physician assistants, or nurse practitioners can prescribe medication).

Referrals can be given for these services if needed.

Yes_____            No______

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4. I/We have been informed of rights regarding confidentiality. Confidentiality may be broken in the following situations without your permission when:

-Child or elder abuse is suspected.

-You are a danger to yourself.

-You are a danger to others.

-The court orders a release of records.

-I am sued form malpractice/when you use your mental health records as a defense in court.

-You request that I share information with someone else. You get to dictate who and what information. (Please complete the form "General Release of Information Permission Form" and share with me before I can share any information).

Yes_____                 No_____

_____________________________________________________________________________________________________________________________5. I/We understand my/our client rights:

-Clients may ask questions and receive answers about treatment.

-Clients may ask about the therapy approach.

-Clients may ask questions about the cost of their services.

-Clients may make decisions about their own lives.

-Clients may end therapy or go to someone else. A final meeting to close up is highly recommended to prevent progress from unraveling.

Yes_____                  No_____

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6. I/We will allow Allison A. Brodeur to provide therapy or any evaluations that are needed.

Yes_____                 No_____

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7. When I/we wish to end therapy, I/we will discuss terminating therapy services, moving to scheduling sessions as needed, or moving to an inactive status. I/we can also ask for referrals to another mental health professional if needed.

Yes_____                 No_____

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8. By typing my full name below, I am giving consent to participate in therapeutic services with Allison A. Brodeur, MS, LMFT, PLLC.

(Please only type your name or the name of your child if they are a minor. All individuals coming to see me as a client, i.e. if I am seeing you and your significant other for couple therapy or you and other family members for family therapy, should complete their own individual file in the system. Please do not fill it out for anyone over the age of 18, as I need for them to give me their permission to work with them.)

Full name of client