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Terms and Policy

Office Policies
Nassau-Suffolk Counseling Services, PLLC
James Sellars, LCSW-R
898 Oyster Bay Road, Suite D
East Norwich, NY 11732
516-364-4728
516-945-0909(fax)
Jamessellarslcsw@gmail.com

OFFICE POLICIES

1. Please be on time for your scheduled appointments. All sessions will begin on time and end on time.

2. All sessions are 45 minutes in duration.

3. If you need to reschedule an appointment, please do so 24 hours prior to your scheduled time. Otherwise full charge for the session is due.

4. Payment is due prior or at each and every session for psychotherapy. For parenting coordination, custody evaluations or other court appointed work, full payment is due prior to the commencement of our time together.

5. If paying with a credit card, an additional 5% charge will be added to the session rate.

6. Any additional time spent on the phone or via email, outside of your scheduled appointment will be billed at the session rate after the first 3 minutes.

7. If for any reason I am required to perform any professional duties for any court a separate rate and retainer agreement will be agreed to between myself and you as my client

Thank you for your cooperation and understanding in advance!!

James Sellars, LCSW-R


Client’s Signature: ________________________________

Date: _______________
( Type Full Name )
Crisis Event
Please be advised, this site should not be used as a means to solicit assistance during an emergency. Please contact your local 911 operator, or go to the nearest emergency department at your local hospital.
( Type Full Name )
Informed Consent for individual Psychotherapy







INFORMED CONSENT TO INDIVIDUAL PSYCHOTHERAPY


This form documents that I, , give my consent to, James J. Sellars, LCSW-R (the "psychotherapist") to provide psychotherapeutic treatment to me.

While I expect benefits from this treatment, I fully understand that no particular outcome can be guaranteed. I understand that I am free to discontinue treatment at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so.

I have fully discussed with the psychotherapist what is involved in psychotherapy and I understand and agree to the policies about scheduling, fees and missed appointments. I understand that I am fully financially responsible for treatment, which, if I have health insurance, includes any portion of the psychotherapist's fees that are not reimbursed by my insurance. I understand that the frequency of my sessions will be
., that I am fully responsible for payment of all deductibles and co­ payments if I have health insurance, that the frequency of billing will be
and that payment will be due at the session that immediately
follows my receipt of a bill, and that I will be personally responsible for payment in full for any canceled session if I do not give the psychotherapist at least 24 hours advance notice of the cancellation (please note that insurers don't pay for canceled sessions).

Our discussion about therapy has included the psychotherapist's evaluation and diagnostic formulation of my problems, the method of treatment, goals and length of treatment, and information about record-keeping. I have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. I understand that therapy can sometimes cause upsetting feelings to emerge, that I may feel worse temporarily before feeling better, and that I may experience distress caused by changes I may decide to make in my life as a result of therapy.

I understand that the psychotherapist cannot provide emergency service. The psychotherapist has told me whom to call if an emergency arises and the psychotherapist is unavailable. In any case, I understand that in any emergency, I may call 911 or go the nearest hospital emergency room.

I understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others unless I give my consent. There are a few exceptions as follows:

1. The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities.

2. If I tell the psychotherapist that I intend to harm another person, the psychotherapist must try to protect that person, including by telling the police or the person or other health care providers. Similarly, if I threaten to harm myself, or my life or health is in any immediate danger, the psychotherapist will try to protect me, including by telling others such as my relatives or the police or other health care providers, who can assist in protecting or assisting me.

3. If l am involved in certain court proceedings the psychotherapist may be required by law to reveal information about my treatment. These situations include child custody disputes, cases where a therapy patient's psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-related treatment.

4. If my health insurance or managed care plan will be reimbursing me or paying the psychotherapist directly, they will require that I waive confidentiality and that the psychotherapist give them information about my treatment.

5. The psychotherapist may consult with other psychotherapists about my treatment, but in doing so will not reveal my name or other information that might identify me. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about my treatment.

6. If my account with the psychotherapist becomes overdue and I do not pay the amount due or work out a payment plan, the psychotherapist will reveal a limited amount of information about my treatment in taking legal measures to be paid. This information will include my name, social security number, address, dates and type of treatment and the amount due.

Inall of the situations described above I understand that the psychotherapist will try to discuss the situation with me, or notify me, before any confidential information is revealed, and will reveal only the least amount of information that is necessary.

If I am participating in a managed care plan, I have discussed with the psychotherapist the plan's limits, if any, on the number of therapy sessions. I have discussed with the psychotherapist my options for continuation of treatment when my managed care benefits end.

I understand that I have a right to ask the psychotherapist about the psychotherapist's training and qualifications and about where to file complaints about the psychotherapist's professional conduct.

By signing below I am indicating that I have read and understood this form and
that I give my consent to treatment.


Signature:___________________________________ Date: _
(of patient or person authorized to consent for patient)
( Type Full Name )
Consent to Couple's and family Therapy








INFORMED CONSENT TO COUPLE OR FAMILY PSYCHOTHERAPY


This form documents that we, , give our consent to James J. Sellars, LCSW-R to provide psychotherapeutic treatment to us.

While we expect benefits from this treatment, we fully understand that no particular outcome can be guaranteed. We understand that we are free to discontinue treatment at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so.

We have fully discussed with the psychotherapist what is involved in psychotherapy and we understand and agree to the policies about scheduling, fees and missed appointments. Our discussion about therapy has included the psychotherapist's evaluation and diagnostic formulation of our problems, the method of treatment, goals and length of treatment, and information about record-keeping. We have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. We understand that therapy can sometimes cause upsetting feelings to emerge, that we may feel worse temporarily before feeling better, and that we may experience distress caused by changes we may decide to make in our lives.

We understand that the psychotherapist cannot provide emergency service. The psychotherapist has told us whom to call if an emergency arises and the psychotherapist is unavailable.

We understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others unless we give our consent. There are a few exceptions as follows:

1. The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities.

2. If one of us tells the psychotherapist of an intention to harm another person, the psychotherapist must try to protect that person, including by telling the police or the person or other health care providers. Similarly, if one of us threatens to harm ourselves, or our life or health is in any immediate danger, the psychotherapist will try to protect us, including by telling others such as relatives or the police or other health care providers, who can assist in protecting us.

3. If we are involved in certain court proceedings the psychotherapist may be required by law to reveal information about our treatment. These situations include child custody disputes, cases where a patient's psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-ordered treatment.

4. If our health insurance or managed care plan will be reimbursing us or paying the psychotherapist directly, they will require that we waive confidentiality and that the psychotherapist give them information about our treatment.

5. The psychotherapist may consult with other psychotherapists about our treatment, but in doing so will not reveal our names or other information that might identify us unless specific consent to do so is obtained. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about our treatment.

6. If our account with the psychotherapist becomes overdue and we do not work out a payment plan, the psychotherapist will have to reveal a limited
amount of information about our treatment in taking legal measures to be paid. This would include our names, social security number, address, dates and type of treatment and the amount due.

In all of the situations described above we understand that the psychotherapist will try to discuss the situation with us before any confidential information is revealed, and will reveal only the least amount of information that is necessary.

We understand that, except in exceptional circumstances, the psychotherapist cannot keep secrets from other family members who are involved in the therapy because this might harm the person who does not know.

We agree that each of us has and shall continue to have the right to information about our individual and conjoint treatment sessions, and to the treatment records of the psychotherapist regarding our individual and conjoint treatment sessions. We each agree that the psychotherapist may release such information or records to either or all of us without any additional authorization(s) of the other(s). We understand that each of us will not, however, have any right of access to information or records regarding individual treatment sessions of other family members.

We agree that if marriage or parenting problems lead to legal disputes over child custody or visitation, neither of us will ask nor require that the psychotherapist testify regarding custody or visitation. If a custody or visitation proceeding does occur, we agree that the psychotherapist's role will be limited to providing to a mental health professional appointed to perform a forensic evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, our treatment; the psychotherapist will provide these either as required by law or upon our authorization.

If we are participating in a managed care plan, we have discussed with the psychotherapist our financial responsibility for any co-payment, and the plan's limits on the number of therapy sessions. We have discussed with the psychotherapist our
options for continuation of treatment when our managed care benefits end. If we are not participating in a managed care program, we understand that we are fully financially responsible for treatment, including any portion of the fees not reimbursed by our health insurance.

We understand that we have a right to ask the psychotherapist about the psychotherapist's training and qualifications and about where to file complaints about the psychotherapist's professional conduct.

By signing below we are indicating that we have read and understood this form and that we give our consent to treatment.


Signature: _ Date:--------
Signature: _ Signature: _
( Type Full Name )