Payment and Cancellation Policies

Fees and Payment

Payment is due at the beginning of each session. You should receive a copy of my current rates with this intake package. Please ask for it if necessary. I will evaluate my fee periodically, which is subject to change based on additional training and expertise, or other factors. Rates listed are for cash/check pricing. If you are paying by check, please make it payable to: Jolene Nell Counseling. A $25.00 fee will be assessed for returned checks. Any outstanding balances will be sent to a collection agency.

I also accept debit and credit cards through Stripe in the client portal in Simple Practice. When paying with credit and debit cards, there will be a small Stripe handling fee added to your total. By signing this document, you are verifying knowledge of this handling fee.

Scheduling

Please handle any administrative details such as future cancellations or rescheduling at the beginning of a session. Future appointments will not be scheduled if sessions remain unpaid. This policy is designed to prevent you from incurring a large bill that may be difficult to pay at a later time.

Other Services and Legal Involvement

In addition to weekly appointments, I charge the same rates for other professional services you may need (with the exception of legal involvement – see below). I will pro-rate the hourly cost if I work for periods less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other service you request of me.

If you are, or become, involved in legal proceedings that require my participation, you will be expected to pay for my professional time - and any legal counsel needed to support my work and protect my professional status and license - even if I am called to testify for another party. Because of the difficulty of legal involvement, I charge $300 per hour for research, preparation and attendance at any legal proceeding. I will not bill insurance companies; however, I will be happy to provide you with a receipt of service that you may submit for reimbursement. You will have to research your individual policy to see what it covers.

Insurance

Most health insurance plans cover some therapy services, and will reimburse for an “out of network provider.” I encourage you to check your plan carefully to determine what is covered under your plan. I am not on any insurance panels. I am happy to provide you with a monthly statement to submit to insurance for reimbursement, per your request.  

Phone Calls and Texts

As an individual therapist in private practice, I am not equipped to respond to emergency texts or phone calls. If you are in need of urgent assistance, you must call your local crisis line or 911. After the crisis is under control, please call me and I will respond as soon as I can. I will make every effort to respond to phone calls and texts requiring a response within 24 business hours (unless I am on vacation). Phone calls lasting longer than five minutes will be billed at my regular hourly rate. Generally, I do not conduct telephone therapy sessions. Exceptions to this policy are made at my discretion. Please note: insurance will not reimburse you for time on the phone with a therapist.

Cancellation and Missed-Appointments Policy: By signing this contract, you are committing to prioritize your appointments with me. To maximize the benefit of therapy in your quest to heal and change, you must commit and be consistent.

If you are unable to keep an appointment for any reason, please leave a message on my voicemail, or send an email or text, at least 24 hours in advance. The full fee is collected for missed or cancelled appointments with less than 24 hours notice. If you are a no-show and do not contact me, you automatically forfeit future appointment times. Lack of response to an automated courtesy text reminder is NOT a cancellation. If you miss or cancel three sessions in a row, or frequently cancel appointments, we will discuss whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist. And finally, if you are late for your session for any reason, the full fee will still be charged. Please note: insurance companies do not reimburse for cancelled or missed sessions. 

Thank you for your consideration and integrity regarding these important matters.

· I acknowledge having received and fully read a copy of the Payment & Cancellation Policies.

· I commit to keeping my scheduled appointments, and guarding my therapy time as a priority on my calendar.

· I agree to the payment and cancellation requirements noted above, understand the policies and their ramifications, and have had the opportunity to ask questions.

· This consent shall be in effect for the duration of treatment, though the specified fee may change.

 

Print your name(s) here: ________________________________________________

Signature: _______________________________________________________________       Date: ________________________________

Signature: _______________________________________________________________       Date: _______________________________ 

(Signed by Client’s Parent/Guardian if under 15 years old in OR, or under13 years old in WA)