Part I: Your Rights as a Client

1. You have the right to ask questions about any procedures used during therapy; if you wish, I will explain my usual approach and methods to you.

2. You have the right to decide not to receive therapeutic assistance from me; if you wish, I will provide the names of other qualified professionals whose services you might prefer.

3. You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already accrued.

4. You have the right to review records in the files at any time.

5. One of your most important rights involves confidentiality: Within certain limits, information

revealed by you during therapy will be kept strictly confidential and will not be revealed to any

other person or agency without your written permission.

6. If you request it, any part of your record in the files can be released to any person or agency you designate. I will tell you, at the time, whether or not I think releasing the information in question to that person or agency might be harmful in any way to you.

7. You should also know that there are certain situations in which I am required by law to reveal information obtained during therapy to other persons or agencies without your permission. Also, I am not required to inform you of my actions in this regard. These situations are as follows: a) if you threaten grave bodily harm or death to another person, I am required by law to inform the intended victim and the appropriate law enforcement agencies. b) If a court of law issues a legitimate subpoena, I am required by law to provide the information specifically described in the subpoena. c) If you reveal information relative to child abuse and neglect, I am required by law to report this to the appropriate authority; and d) if you are in therapy or being tested by order of a court of law, the results of the treatment or tests ordered must be revealed to the court

Part II. The Therapeutic Process

One major benefit that may be gained from participating in therapy includes a better ability to handle or cope with marital, family, and other interpersonal relationships. Another possible benefit may be a greater understanding of personal goals and values; this may lead to greater maturity and happiness as an individual. Other benefits relate to the probable outcomes resulting from resolving specific concerns brought to therapy. In working to achieve these potential benefits, however, therapy will require that firm efforts be made to change and may involve the experiencing of significant discomfort. Remembering and therapeutically

resolving unpleasant events can arouse intense feelings of fear, anger, depression, and frustration. Seeking to resolve issues between family members, marital partners, and others persons can similarly lead to discomfort, as well as relationship changes that may not be originally intended.

Part III: Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who insured but does not plan to use their insurance benefits to pay for health care items and/ or services. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your mental health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you or your child. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

Good Faith Estimate:

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. Depending on environmental factors, family dynamics and ability to implement therapeutic tools, you may need between 20 to 40 sessions this year. I agree to pay $225.00 for each completed (fifty three minute session). I understand that payment is expected at time of session. Devine Counseling Services LLC recognizes every client’s therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:

● Your schedule and life circumstances

● Therapist availability

● Ongoing life challenges

● The nature of your specific challenges and how you address them

● Personal finances

● Ability to implement therapeutic tools and strategies

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/ or a new “Good Faith Estimate” will be issued should the frequency of session(s) or needs change. As related, you may request a new GFE at any time in writing during your treatment.

Good Faith Estimate Disclaimer:

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. Your provider may recommend additional services that are not reflected in this

Good Faith Estimate:

The Good Faith Estimate is only an estimate—actual items/ service charges may differ. The Good Faith Estimate does not include any unknown or unanticipated costs that may arise and are not reasonably expected during treatment due to unforeseen events. You could be charged more if complications or special circumstances occur. Other potential items and/ or services associated with therapy charges may include but is not limited to no show/ late cancellation fee(s), record request(s), letter writing(s), legal fee(s)/ court attendance(s), professional collaboration(s), and in-between session supports). These potential items / services and associated fee(s) are discussed further within the Informed Consent documentation and should these items / services be initiated a new Good Faith Estimate will be provided. The Good Faith Estimate does not obligate the client to obtain listed items or services. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate. With my signature, I am saying that I agree to get the items or services from Devine Counseling Services, LLC.. With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:

● I’m giving up some consumer billing protections under federal law.

● I may get a bill for the full charges for these items and services, and have to pay out-of-network under my health plan.

● I was given a written notice that my provider is not in my health plan’s network, the estimated

cost of services, and what I may owe if I agree to be treated by this provider or facility.

● I got the notice either on paper or electronically, consistent with my choice.

● I fully and completely understand that some or all amounts I pay might not count toward my

health plan’s deductible or out-of-pocket limit.

● I can end this agreement by notifying Devine Counseling Services in writing.

● You can choose to get care from a provider or facility in your health plan’s network.