Please Complete the Professional Services Agreement Form

There are 2 ways you can do this:

  1. You can download this form CLICK HERE – fill it out and bring it back with you when you come for your first session
  2. You can fill out the form below and submit your information online prior to your first session

 

 

 

Lynn Carroll, LMHC
The Therapy Space

PROFESSIONAL SERVICES AGREEMENT

In order to ensure that our relationship is based on mutual understanding and to clarify the nature of a therapeutic relationship, please read this contract carefully. Please initial each category after reading it to indicate your understanding of the terms of our relationship. This is not a legal document.

  • A typical session is 50 to 55 minutes, although longer sessions can be scheduled by mutual agreement and agreed-upon fee.
  • Lynn Carroll’s fee for individual sessions is $150.00 an hour. Payment in full is due at the time services are rendered. The fee may be paid by credit card (MasterCard or Visa), check, PayPal or cash. A receipt for the service can be provided if you wish to submit to your insurance carrier for reimbursement, although reimbursement is not guaranteed. Your fee applies to but is not limited to these services: the therapy session, telephone calls, conferring with other professionals regarding your treatment.
  • In the event you pay by credit card, please be aware that this service is merely a courtesy and accommodation to you. For these reasons, please understand that using your card represents, warrants and promises you will not stop payment or otherwise advise the credit card company to stop payment or dishonor the charges for services and you expressly waive any right to stop payment or otherwise cancel credit card charges for services rendered.
  • Please give 24 hours notice of cancellation of appointments or you will be responsible for your full fee. Of course, you will not be charged if you miss an appointment in the event of an emergency.
  • A $20.00 fee in addition to your usual charge will be credited to your account if your check does not clear.
  • In the event that the services of an attorney or collection agency are used to collect any unpaid balance their fee will be charge to you. There is also a separate schedule in the event that I am required to be involved in litigation because of services provided you or litigation that requires my attention regarding you as my client. These fees will include a retainer fee, a forensic fee, and out-of-the-office time charges. These fees will be agreed upon and paid before the forensic services are provided.
  • Messages received by voice-mail will be returned regularly throughout the business day. Messages received after 5 p.m. will be returned the following business day. If your message is not returned in a timely manner and you require assistance, please call your primary care physician, 911 or go to your local hospital emergency room for assistance.
  • I live and work in this community and it is possible we will encounter each other in public. I will not acknowledge or speak to you unless spoken to. Please do not be offended; this behavior is to protect your confidentiality.
  • If you should decide to terminate therapy and we have not discussed this termination, I will close your file after 30 days of no contact. Please understand that this is done to protect both of us from any liability, especially as I would no longer be the treating therapist.
  • Emails, texting and any other forms of social communications are not confidential documents. Please be careful to limit your communications to making and changing appointments in case others see them.
  • Please authorize Lynn Carroll to charge your credit card after each session. This will expedite payment and provide convenience to your therapy experience. This information will be strictly confidential.