Patient Clinician Agreement

Anchor Counseling Center Patient Clinician Agreement

Patient Clinician Agreement

Revised 2/19/19

This document contains important information about therapy services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), the federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which has also been provided to you, explains HIPAA and its application to your personal health information in greater detail, and my practice in general accordance with HIPAA policies. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of this session.


Therapy is a relationship between a therapist, individual, and or family members that work in part because of the clearly defined rights and responsibilities held by each person.  As a patient of psychotherapy, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. Anchor Counseling Center has corresponding responsibilities to you. These respective rights are described in the following section.

Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as: sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part & ours. In order to be most successful, you will have to work on the issues that will be discussed outside of sessions.

The first few sessions will involve a comprehensive evaluation of your needs. By the end of that time, we will be able to offer you some initial impressions of what our work may include. At that point, we will discuss your treatment goals and create a personalized, initial treatment plan, if you decide to continue. You should evaluate this information as well as your own assessment about whether you feel comfortable working with me. Therapy involves a large commitment of time and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise.


If psychotherapy has begun, I will usually establish a regular schedule with you. Most times in the beginning of treatment (1) 45 minute session weekly is warranted unless we decide more frequent (or Bi-weekly) appointments are needed. I have a flexible schedule and usually can accommodate most requests for appointment times.


Therapy is most effective when meeting times are regular and consistent. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, it is required that you provide more than 24 hours’ notice. If you miss a session without cancelling, or cancel within less than 24 hours’ notice, you must pay $60 for individual sessions and family sessions ($120 for an initial session/$250 for an initial session with the Psychiatrist) and $100.00 for follow ups with the psychiatrist. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. In addition, you are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will still need to end on time. If there is a pattern of missed appointments, especially without providing 24 hours’ notice, Anchor reserves the right to terminate your treatment with the appropriate referrals.


Psychotherapy sessions are 45 minutes and billed at $120 per hour (initial sessions are $180; other fees are dependent upon service provided and will be arranged at the time of service). Psychiatric sessions are 20 minute sessions are billed at $150.00. Session fees or insurance co-pays are payable at time of service. You will be responsible for paying the entire fee if your insurance fails to authorize units of service or if no units of service are available to you.  Anchor’s cash rates are $120 for an initial appointment, $80 for individual follow ups and $86 for family or couple follow ups.  Moreover, legal fees ($125 per hour of service provided) are not billable to insurance companies and will be charged to the patient directly (e.g. court evaluations, recommendation letters, treatment summaries, & court appearances). Should a balance accrue and no payment is received, Anchor Counseling Center, Inc. reserves the right to seek reimbursement by any means legally possible including, but not limited to, the retention of a collection agency.

Payments can be made via Cash, Apple Pay, American Express, Discover, Visa or Master Card. Please note that all co-payments are due on the date of service.


Anchor Counseling Center, Inc. accepts payment directly from many insurance companies. In the event that we are not a participating provider in your managed care plan, my services are typically reimbursable out of network and we will provide you with a monthly statement that you may submit to your insurance to obtain out-of network reimbursement. Please check with your insurance carrier as soon as treatment begins as they may not adhere to out-of network reimbursement.


The confidentiality of all communications between a patient and a mental health counselor is generally protected by law, as your therapist, we cannot and will not tell anyone else what you have discussed or even that you are in therapy without your written permission. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. With the exception of certain specific situations described below, you have the right to confidentiality of your therapy. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time.

Exceptions in which we are legally bound to take action even though that requires revealing some information about a patient’s treatment. If at all possible, we will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:

  • If there is good reason to believe you are threatening serious bodily harm to yourself or others. If we believe a client is threatening serious bodily harm to another, we may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens harm to him/herself or another, we may be required to seek hospitalization for the client, or to contact family members or others who can provide protection.
  • If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, we are required by law to file a report with the appropriate state agency.
  • In response to a court order or where otherwise required by law.
  • To the extent necessary, to make a claim on a delinquent account via a collection agency.
  • To the extent necessary for emergency medical care to be rendered.

Finally, there are times when we find it beneficial to consult with colleagues as part of my practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed unless you consent and request coordination between therapists within Anchor Counseling Center.


We are required to keep appropriate records of the psychological services that we provide. Although psychotherapy often includes discussions of sensitive and private information, records are kept, what was done in session, and a mention of the topics discussed, and treatment goals. All are records are stored in an electronic medical record.


We are usually not immediately available by telephone. While there is staff in the office during normal business hours, they are only able to take a message. We are in the office several days a week, at various times of the day, but usually in session. If you need to reach me between sessions, or in an emergency, you may leave a message on our confidential voicemail or with the reception staff at any time and your call will be returned as soon as possible or by the next business day under normal circumstances.

On weekends & holidays, we typically do not check messages. If you require an immediate response, you may call our emergency line at 872-222-7403.  But, for any number of unseen reasons, if you do not here from us or we are unable to reach you, it remains your responsibility to take care of yourself until we can talk. If you feel unable to keep yourself safe, go to your nearest emergency room. We will make every attempt to inform you in advance of any planned absences, and provide you with a name and phone number of the therapist covering the practice.


Anchor does not accept friend or contact requests from current or former clients on any personal social networking site (Facebook, LinkedIn, etc.). Anchor believes that adding clients as friends or contacts on personal sites can compromise your confidentiality and our privacy. It may also blur the boundaries of the therapeutic relationship.

Anchor Counseling Center keeps a Facebook Page, Twitter account, Instagram for professional practice to allow people to share blogs, posts and practice updates with other social media users. Anchor Counseling Center also has a LinkedIn account for professional use. You are welcome to view the Anchor Counseling Center social media accounts mentioned above to read or share articles posted there. Anchor Counseling Center posts psychology news on Twitter, Instagram, LinkedIn, and Facebook. There is no expectation that you as a client have to follow these sites. Our primary concern is your privacy. If you share this concern, there are more private ways to follow us on Twitter (such as using an RSS feed or a locked Twitter list), which would eliminate having a public link to the content. You are welcome to use your own discretion in choosing whether to follow the Anchor social media sites. Note that you will not be followed back. In addition, if your therapist finds that the two of you are linked in any way through mutual individuals, those individuals will be blocked from your therapist’s social media site. We only follow other health professionals on Twitter, Instagram, Facebook and LinkedIn and do not follow or accept current or former clients on blogs, LinkedIn, Twitter, Instagram or Facebook. If there are things from your online life that you wish to share with your therapist, please bring them into your sessions where you can view and explore them with your therapist, during the therapy hour.

Your therapist will not search for you on any search engine or social media platform.   There are times when staff might complete an online search of a judiciary website if there is a safety concern.


Please do not use text messaging or messaging on Social Networking sites to contact your clinician. These sites are not secure and your clinician may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with your clinician in public online if we have an already established client/therapist relationship. Engaging with your clinician this way could compromise your confidentiality. Also, these exchanges may become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact your therapist, the best way to do so is by phone. Your therapist has their own extension with voicemail that you may call at any time. Direct email is also an option and your therapist has an individual email account as well. Email is the second best for quick, administrative issues such as changing appointment times.


The use of recording devices in the therapy session are strictly prohibited. This includes but is not limited to recording on cell phones and/or audio recorders. We understand that during the therapy hour, many issues are being discussed that may not be absorbed strictly through memory. Therefore, speak to your therapist about how you want to document what is discussed in the session. Many clients take notes while in therapy so they can capture the important topics discussed. Sometimes, the therapist may make a list at the end of the session to summarize what they want you to work on and/or remember from the session. It is important to speak to your therapist about how you are going to capture the content of your session. If you need accommodations or recording the sessions is absolutely necessary, speak to your therapist about this matter and they will be happy to come to a reasonable compromise.


If you are unhappy with what is happening in therapy, I hope you’ll talk with the therapist so that we can respond to your concerns. Such criticism will be taken seriously and with care and respect. You may also request that we refer you to another therapist and are free to end therapy at any time.

You have the right to ask questions about any aspect of the therapy and about our specific training and experience.


  • The office phone is 401-475-9979. Please use this number for all routine matters, including appointment changes, scheduling, or a non-emergent concern. In the event of a clinical emergency & you are unable to reach us, please call 911 and proceed to your nearest emergency room.
  • Office hours typically are 9am-5pm (Monday-Friday), however we have a varied scheduled (including evening appointments).
  • Late cancellation & No Show fees must be paid prior to your next visit.
  • In the event of inclement weather it is your responsibility to call and cancel your appointment if you do not feel safe driving.
  • I understand that if I do not make payments for the services not covered by insurance, that Anchor Counseling Center, Inc. reserves the right to suspend or terminate treatment, with appropriate notice and will assist you in making a referral elsewhere.
Patient Clinician Agreement