Terms and Conditions | Sallie West, MA, MFT

TERMS OF SERVICE & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

This form contains important information about Sallie West's professional services and business policies. Please read it carefully, and feel free to raise any thoughts or questions you may have. When you sign this document, it will represent an agreement between you and Sallie West.

THE PROCESS OF THERAPY/EVALUATION

I believe you have made a significant step toward caring for yourself and your family by seeking therapy. Therapy requires courage and a personal commitment to your growth and future. It takes work. Sometimes you can experience difficult feelings/memories and possibly experience effects in your relationships relative to the changes that can occur as a result of the therapeutic process. During the course of therapy, I will draw on various psychological approaches according, in part, to the problem that is being treated and the assessment of what will best benefit you. These approaches include but are not limited to behavioral, cognitive-behavioral, psychodynamic, theological, psycho-educational, schema therapy, mindfulness based cognitive therapy, expressive arts/movement therapy, Buddhist psychology, chakra psychology and the Enneagram.

Not all issues or problems are appropriate for telephone therapy. It is up to the discretion of the therapist as to whether your needs would be better addressed by face to face therapy. In addition, I have an ethical obligation to inform you of other treatments that may be more beneficial.

PRIVACY & CONFIDENTIALITY

Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony of your therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your therapist will use her clinical judgment when revealing such information. Your therapist will not release records to any outside party unless it is authorized to do so by all adult family members who were part of the treatment.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on your therapist, Sallie West to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

TELEPHONE & EMERGENCY PROCEDURES

If you need to contact your therapist between sessions, please call (802) 496-7135. Your call will be returned as soon as possible. Messages are checked daily (but never during the night time). Messages are checked less frequently on weekends and holidays. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call the emergency National Hopeline at 800-784-2433, dial 911 or go to the emergency room.

PAYMENTS

Session payments via credit or debit card can be processed through PayPal. Sessions are purchased in 1 hour (60 minute) blocks.

FEES

Session fees are $120/hour.

Report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate of $120. per hour, unless indicated and agreed otherwise.

Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.

Discounts are available for multiple sessions. Session fees and discounts are subject to change at any time.

CANCELLATION

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

AS NOTED ON SALLIEWEST.NET:

I understand that telephone/online psychotherapy with Sallie West is not a substitute for medication under the care of a psychiatrist or doctor. I understand that telephone therapy is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. If a life-threatening crisis should occur, I agree to contact a crisis hotline, call 911, or go to a hospital emergency room. I also understand that Sallie West follows the laws and professional regulations of the State of Vermont (USA) and that psychotherapy treatment will be considered to take place in the state of Vermont (USA). I have been provided with the HIPAA Notice of Privacy Practices.

I have read the above Agreement carefully; I understand them and agree to comply with them:

TERMS OF SERVICE & GENERAL INFORMATION  AGREEMENT FOR PSYCHOTHERAPY SERVICES     This form contains important information about Sallie West's professional services and business policies.  Please read it carefully, and feel free to raise any thoughts or questions you may have.  When you sign this document, it will represent an agreement between you and Sallie West.    THE PROCESS OF THERAPY/EVALUATION    I believe you have made a significant step toward caring for yourself and your family by seeking therapy.  Therapy requires courage and a personal commitment to your growth and future.  It takes work.  Sometimes you can experience difficult feelings/memories and possibly experience effects in your relationships relative to the changes that can occur as a result of the therapeutic process.  During the course of therapy, I will draw on various psychological approaches according, in part, to the problem that is being treated and the assessment of what will best benefit you.  These approaches include but are not limited to behavioral, cognitive-behavioral, psychodynamic, theological, psycho-educational, schema therapy, mindfulness based cognitive therapy, expressive arts/movement therapy, Buddhist psychology, chakra psychology and the Enneagram.   Not all issues or problems are appropriate for telephone therapy.  It is up to the discretion of the therapist as to whether your needs would be better addressed by face to face therapy.  In addition, I have an ethical obligation to inform you of other treatments that may be more beneficial.     PRIVACY & CONFIDENTIALITY    Confidentiality:  All information disclosed within sessions and the written records pertaining to those  sessions are confidential and may not be revealed to anyone without your (client’s) written permission,  except where disclosure is required by law.  Most of the provisions explaining when the law requires  disclosure were described to you in the Notice of Privacy Practices that you received with this form.     When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the  law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a  client presents a danger to self, to others, to property, or is gravely disabled (for more details see also  Notice of Privacy Practices form).     When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding.  If you  place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain  the psychotherapy records and/or testimony of your therapist.  In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  Your therapist will use her clinical judgment when revealing such information. Your therapist will not release records to any outside party unless it is authorized to do so by all adult family members who were part of the treatment.      Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves  making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed  that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries,  lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on  your therapist, Sallie West to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.      TELEPHONE & EMERGENCY PROCEDURES     If you need to contact your therapist between sessions, please call (802) 496-7135.  Your call will be returned as soon as possible. Messages are checked daily (but never during the night time).  Messages are checked less frequently on weekends and holidays.  If an emergency situation arises, please indicate it clearly in your message.  If you need to talk to someone right away, you can call the emergency National Hopeline at 800-784-2433, dial 911 or go to the emergency room.       PAYMENTS   Session payments via credit or debit card can be processed through PayPal.  Sessions are purchased in 1  hour (60 minute) blocks.    FEES     Session fees are $120./hour.     Report writing and reading, consultation with other professionals, release of information, reading records,  longer sessions, travel time, etc. will be charged at the same rate of $120. per hour, unless indicated and  agreed otherwise.       Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.       Discounts are available for multiple sessions.  Session fees and discounts are subject to change at any time.     CANCELLATION    Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24  hours notice is required for re-scheduling or canceling an appointment.  Unless we reach a different  agreement, the full fee will be charged for sessions missed without such notification.     AS NOTED ON SALLIEWEST.NET:    I understand that telephone/online psychotherapy with Sallie West is not a substitute for medication under the care of  a psychiatrist or doctor. I understand that telephone therapy is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. If a life-threatening crisis should occur, I agree to contact a crisis hotline, call 911, or go to a hospital emergency room. I also understand that Sallie West follows the laws and professional regulations of the State of Vermont (USA) and that psychotherapy treatment will be considered to take place in the state of Vermont (USA). I have been provided with the HIPAA Notice of Privacy Practices.   I have read the above Agreement carefully; I understand them and agree to comply with them:

Client Name:		Date:
Client Name:		Date: