Terms & Conditions

Pamela Kohll, MS, LPCC, CST, CSAT-S

NY. License # 6316
NE License # 2515
CA License # 7631
IA License # 127244
917 574-9034

Welcome to my virtual office through Zoom tele-counseling. 

The following document is designed to give you information about my professional services and business policies. Please read this carefully. If you have any questions or concerns, please ask me at your first session, or as they arise during the course of treatment. 

Please note that when you sign this form, it represents an agreement between us.

Kindly complete these forms and email them back to me before our first session.

Agreement for Service and Informed Consent

Introduction

This agreement is intended to provide ________________________ (herein “Client”) information regarding the practices, policies, and procedures of Pamela Kohll, (herein “Therapist”) and to clarify the terms of the professional therapeutic relationship between therapist and client. Any questions or concerns regarding the contents of this agreement should be discussed with Therapist prior to signing it. Therapist has been practicing as a licensed professional clinical counselor for 25 years, working with individuals and couples, as well as facilitating group therapies. Therapist’s theoretical orientation can be described as psychodynamic, and relational, with an emphasis on Attachment Theory.

Our first few sessions will involve the evaluation of your needs. Client should address any concerns s/he has regarding progress in therapy with Therapist. During this initial period I want you to evaluate your comfort level with me as your therapist and address any questions you have about the process.

Risk and Benefits of Therapy

Psychotherapy is a process which Therapist and Client discuss a myriad of issues, events, experiences and memories so Client can experience his/her life more fully. It provides an opportunity to better and more deeply understand oneself, as well as any problems or difficulties Client may be experiencing. Psychotherapy is a joint effort between Client and Therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors.

Participating in therapy may result in a number of benefits to Client, including but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self confidence.

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which Therapist will challenge Client’s perceptions and assumptions, and offer different perspectives. The issues presented by Client may result in unintended outcomes, including changes in personal relationships. Client should be aware that any decision on the status of his/her personal relationships is the responsibility of Client. There are no guarantees about what you will experience, or when, or how fast you will feel improvement.

Confidentiality

The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client, except where required or permitted by law. Exceptions to confidentiality, include , but are not limited to, reporting child, elder and dependent adult abuse, when a client makes a serious threat of violence, towards a reasonably identifiable victim, or when a client is dangerous to him/herself or the person or property of another. In certain legal situations, such as in a child custody case or when your emotional condition is an issue, (for example in a Worker’s Compensation or personal injury case), the judge may order me to testify. In the event that an account with me goes unpaid, it is legal for me to disclose your name, dates of sessions, and amount due to a collection agency, or small claims court as necessary.

All mental health professionals are bound by the same rules of confidentiality. I have been given training about protecting your privacy and have agreed not to release confidential information outside of my practice without appropriate authorization for disclosure, or one of the above listed mandates and or emergencies.

Federal law under the Patriot Act states that when the federal government believes an individual to be a threat to national security, the government may access an individual’s therapy records with a federal warrant. In the unlikely event that this occurs, the Therapist will not disclose to the Client that this event happened.

Confidentiality with Family and Couple’s Therapy 

When working with family members and couples, I ask all parties to sign releases of information so that I may share relevant information and give important feedback to all those participating in treatment. In situations where one family member or one partner requests that I release information about the family or couple’s sessions, it is my policy not to release information unless all family members (or both members of the couple) sign an authorization allowing me to do so.

I will not hold a secret between the couples when working with couples. I also will not divulge to the partner what the secret is, and will work to support the client to disclose to his/her partner the secret. I will give the client reasonable time to do so, for instance 30 days, and if he/she cannot do so, then I will terminate the couples therapy and refer out to another clinician.

Psychotherapist-Patient Privilege

The information disclosed by Client, as well as any records created is subject to the psychotherapist-client privilege. The psychotherapist client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney/client privilege or the doctor/patient privilege. Typically the client is the holder of the psychotherapist client privilege. If therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, therapist will assert the psychotherapist client privilege on client’s behalf, until instructed in writing, to do otherwise by client or client’s representative. Client should be aware that she/he might be waving the psychotherapist client privilege if she/he makes mental or emotional state an issue in a legal proceeding. Client should address any concerns she/he might have regarding the psychotherapist client privilege with his/her attorney.

There are however exceptions to privilege, which includes but is not limited to : If 1) a client is a danger to self or others, 2) a judge issues a court order, 3) a client introduces her/his mental condition into testimony, 4) someone is under 16 and is a victim of a crime, 5) the court is using therapy to establish sanity or competence to stand trial, 6) a client has treated information as though it is not confidential, 7) information pertaining to the Patriot Act, 8) information listed on a health insurance claim form or child abuse report, 9) a client files a complaint or a lawsuit against me.

Professional Consultation

Therapist may regularly participate in clinical, ethical and legal consultation in consultation with another therapist colleague. During such consultations, Therapist will not reveal any personally identifying information regarding client. For professional consultations with people with whom you have asked or allowed me to speak (physicians, attorneys, school teachers, other clinicians) I charge in quarter hour segments (for calls that are more than 15 minutes). I also charge for time writing letters and reports about your case or reading extensive reports. I will notify you about these charges before beginning these activities. These are charges that usually insurance companies do not reimburse for. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time, even if I am called to testify by another party.

Clinical records are maintained in a secure confidential manner during treatment and for 7 years after termination of treatment, and/or 7 years after a client turns 18. After 7 years clinical records will be destroyed in a confidential manner and cannot be accessed. If within the 7 years following treatment, for any reason I am not in practice at that time, or upon my death, I will designate another mental health professional to continue to secure and maintain my records and you will be notified of the therapist’s name just in case you need to access records at a later time.

Records and Record Keeping

Therapists may take notes during session and will also produce other notes and records regarding client’s treatment. These notes constitute therapist’s clinical and business records which by law therapist is required to maintain. Such records are the sole property of therapist. Therapist will not alter the normal record keeping process at the request of client. Should client request a copy of records, such a request must be made in writing. Therapist reserves the right to provide client with a treatment summary in lieu of actual records. Therapist also reserves the right to refuse to produce a copy of the record under certain circumstances but may as requested, provide a copy of the record to another treating health care provider. Therapist will maintain client’s records for 7 years following termination of therapy. However after this time, client’s records will be destroyed in a manner that preserves client’s confidentiality.

Patient Rights

HIPPA provides you with several new or expanded rights with regard to your clinical records and disclosures of protected health information. These rights include requesting that I amend your record, requesting restrictions on what information from your clinical record is disclosed to others, requesting an accounting of most disclosures, of protected health information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about my policies and procedures in your records, and the right to a paper copy of this agreement, the attached notice form, and my privacy policy and procedures. I am happy to discuss any of these rights with you.

Minors and Parents

Patients under 18 years of age who are not emancipated generally require parental consent in order to begin treatment. Parental consent must come from a parent or guardian with legal custody. If your minor is the subject of a divorced union it is appropriate to bring a copy of your most recent custody agreement in order to initiate consent for treatment.

Client Litigation

Therapist will not engage in any litigation, or custody dispute in which client and another individual, or entity are parties. Therapist has a policy of not communicating with client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in client’s legal matters. Therapist will generally not provide records or testimony unless compelled to do so. Should therapist be subpoenaed, or ordered by court of law, to appear as a witness in an action involving client Client agrees to reimburse Therapist for any time spent in preparation, travel, or other time in which therapist has made herself available for such an appearance at Therapist’s usual and customary hourly rate of $300.00 an hour.

Fee and Fee Arrangements

The usual and customary fee for service is $300.00 for a full hour session. I do not take any insurances. Pay is fee for service, and I send you a detailed receipt for you to turn into your insurance company. Sessions longer than that are charged for additional time pro rata. Therapist reserves the right to periodically adjust the fee. Patient will be notified of any fee adjustment in advance. In addition, in the future, this fee may be adjusted by the Therapist. If so, there will be a 30 day advance notice.

From time to time Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time to time, Therapist may engage in telephone contact with third parties at the client’s request and with Client’s request and with client’s advanced written authorization. Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than 10 minutes. Clients are expected to pay for services at the time services are rendered.

Therapist keeps your credit card information on file, and will charge your card the day of your appointment.

There is a space at the end of this consent form to complete your credit card information. You are responsible to let me know if the credit card number changes.

If you become involved in a legal proceeding that requires my participation, you will be responsible for all of my professional time, including preparation and transportation costs, and if I am called to testify by another party. My rate is my hourly rate of $300.00 an hour. Fees must be paid in advance and are not reimbursed by medical insurance. 

Missed Sessions and Cancellation Policy

If you are late your appointment will still have to end on time for the courtesy of my next client, and the fee remains the same because your fee is based on the amount of time reserved, not the amount used. I want to hear from you via TEXT at my number 917-574-9034, if you are late or need to cancel your appointment. I require a 48 hour cancellation window or you will be charged for the missed appointment. If you have an appointment on Monday, I will need to hear from you by late Friday, or you will be charged for the missed appointment.

If there is a true emergency, you will not be charged. I prefer not to see you if you are very sick, and will work to try to help you reschedule. Insurance will not reimburse for missed appointments. If you miss a session or cancel late, your insurance company will not help you cover the fee for that session. If you have a set session time and you fail to show up or cancel in advance for 3 consecutive weeks, I will assume you are no longer interested in that time slot and make it available to other clients.

Client is responsible for payment of the agreed upon fee for any missed sessions, or cancellations that are not 48 hours advanced notice.

Texting and Emails

No therapy will be done via email exchanges or texting. These 2 modes of communication are solely for appointment changes or notices. Also, emails should be considered carefully because I cannot guarantee the confidentiality of the Internet or your work or personal devices.

Medical Health Insurance

Therapist is not on any insurance panels and all fees will be paid day of service via your credit card that is kept on file. Therapist will send a detailed receipt with an ICD-11 and CPT code and other details for Client to get reimbursed for, if he/she wishes, and if the insurance company complies. Therapist does not spend time working with insurance companies and reimbursement of fees. This is entirely up to Client to pursue.

Therapist Availability 

Therapist has a confidential voicemail for Client to leave a message, and will return any phone call within 24 hours, unless out of the country or on vacation, which you will be aware of. Therapist is unable to provide 24 hours crisis service. In the event that Client is feeling unsafe or requires medical or psychiatric assistance, she/he should call 911, or go to nearest emergency room.

Termination of Therapy

Therapist reserves the right to terminate therapy at her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs are outside of Therapist’s scope of competence or practice, or Client is not making adequate progress in therapy. Client has the right to terminate therapy at her discretion. Upon either party’s decision to terminate therapy, Therapist will generally recommend that Client participate in at least one, or possibly more termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Client.

Acknowledgement

By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client has discussed such terms and conditions with Therapist, and has had any questions with regard to its terms and conditions answered to Client’s satisfaction. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with the Therapist. Moreover, Client agrees to hold Therapist free and harmless from any claims, demands or suits of damages from any injury or complications whatsoever, save negligence, that may result for such treatment.

Patient Name (please print) ______________________________________________________________

Signature_____________________________________________________

Date ________________________

Patient Name (please print) ______________________________________________________________

Signature_____________________________________________________

Date ________________________

Therapist Signature ______________________________________

Date _______________________

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact me here: https://www.sexhealththerapy.com/connect.