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W. R. MERCER
COUNSELING SOLUTIONS 610 357 8715 ^^ mercergo@gmail.com |
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* IMPORTANT NOTICE * Rev 2/12/08 I. FINANCIAL INFORMATION FOR ALL CLIENTS |
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[ ] No insurance plans will be processed in any way by this office; if you desire to use your insurance, you must handle all the paper work and not involve this office. [ ] Payment is due at the time of the session. Fees are at the rate of $60 per session. [ ] There is a $15 charge for missed appointments if you have not given at least 24 hours notice. [ ] All phone calls longer than 5 minutes are billed at the rate of $10 per 15
minutes or portion thereof. [ ] From time to time, the counseling process may require the use of other resources such as books, tapes or CDs. The cost of these items is in addition to your hourly rate. [ ] The counseling session is 50 minutes; appointment scheduling and payment must be completed in this time frame. |
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| II. CONFIDENTIALITY | |
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A written case record containing personal data, interview notes, and, as
used, test results, will be kept for each client. This information
is privileged and will be held in strict professional confidence.
However, confidentiality is modified under the following conditions: |
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_____________________________ Signature |
_______________ Date |