Jim Colbert, M.Ed., LPC

Phone (512) 569-7573 Fax (512) 819-0256                3008 Dawn Dr., Suite 101, Georgetown, Texas 78628

                                                     email: colbertjmc@gmail.com                                       Webpage: www.jcolbertlpc.com

 

Client/Therapist Contract

The counseling relationship is a professional process intended to help you resolve personal challenges, adapt to life changes, or explore your current life situation.  Some may enter counseling to identify goals and to develop a plan to achieve these goals, overcome or learn to live with a mental illness or disability, to change a behavior, or seek support.  Your therapist will employ a variety of educational and therapeutic techniques, specifically affective (feeling) behavioral (doing) and cognitive (thinking) to help you achieve your personal counseling goals.  These may include out of session counseling exercises or homework.  Some clients can accomplish a great deal in a short period of time.  Those with complex issues or histories will require more time.  Just as people are unique so is their therapy program.  Your therapist is an LPC.  If at any time during the therapeutic process you are dissatisfied with your therapist services please let him know.  If he is unable to resolve your concerns, you may report your complaint to the appropriate state board.  LPC’s are licensed by the Texas State Board of Examiners of Professional Counselors. The board may be contacted for complaints at 1-800-942-5540.

 

Counseling is a very intimate process emotionally and psychologically.  Your therapist’s role is to help guide you through this process.  Your relationship will be purely professional.  Licensed Mental Health Practitioners are held to strict ethical guidelines and are prohibited from having any dual relationships with their clients.  Your contact with your therapist will be limited to paid sessions only.  The therapeutic process has a very distinctive beginning, working stage, and a conclusion.  Closure at the termination of therapy is important for you to have an opportunity to review and internalize what you have gained.  In some cases, termination of therapeutic services may be necessary prior to planned therapeutic termination.  Examples of these cases are non-payment for services, threatening or abusive behavior toward the therapist, or consistently missed or canceled appointments. 

 

You will need to complete a social history (your personal story) prior to or during your first session.  You and your therapist will begin by reviewing any further information that may be pertinent to you.  If another professional (physician, minister, school personnel, or attorney) referred you or if any other information needs to be collected your therapist will ask you to sign a limited and specific release of information. You will then work on identifying your reasons for pursuing therapy and develop a realistic goal and plan. 

 

If you are seeking services for a minor child or adolescent, by signing this contract you are affirming that you, as the custodial parent or guardian, have the legal right present the minor, sign any contracts as they may pertain to the minor, consent to release of information for the minor, and consent to the minor actively participating in counseling and in the therapeutic process.  The therapist may require you to participate in family sessions in addition to the child’s individual sessions.  If parents are divorced your therapist will require you to provide him a copy of the divorce decree as it pertains to custody and parental rights to consent to psychological/mental health treatment.  It is your responsibility to present the divorce decree or custody agreement in either print or digital format to the therapist. 

 

All of your sessions will become part of your clinical record.  Your communication is privileged.  Your therapist will keep confidential anything you say to him or her, with the following exceptions: 1) you authorize she or he to tell someone else, as in the case with insurance reimbursement, or consultation with other professionals, 2) If your therapist is ordered by the court to disclose your information, 3) If your therapist determines that you are a danger to yourself or to others, 4) If during session she or he becomes aware that there is physical abuse, sexual abuse, or neglect to a child or an aged adult.  He or she is required to report to the State of Texas Protective Services. 5) Your therapist must also disclose to the proper authorities if there has been sexual abuse perpetrated by a minister or therapist, or if there has been a life-threatening felony unreported.  In the event of your therapist’s death or incapacitation, all records will be transferred to another licensed mental health counselor.  A notice will be placed in the Williamson County Sun and in the reception area advising clients to contact the mental health designee or the executor of the therapist’s estate to have records transferred to another mental health practitioner.  Any records not picked up or transferred within six months of the therapist’s incapacitation or death will be destroyed by shredding or fire.

Initial assessments are 50-80 minutes.  Individual sessions will be scheduled regularly for 45-50 minutes each.  Please arrive promptly. If you fail to cancel your appointment or show up for your scheduled appointment, you will be billed a $50.00 cancellation fee. If you are late for your scheduled session, that session will be shortened by the amount of time you are late. If there has been an emergency please call, and then you and your therapist will discuss it during your next session.  Clients will not be responsible for missed appointments due to a true emergency. The office will be closed for all major holidays.  Barring emergency or illness your therapist will let you know in ample time when she or he will be away from the office due to training, vacation, or family obligations.

 

If you urgently require assistance and cannot reach your therapist please call the crisis hotline at 512-472-4357, Bluebonnet Trails Emergency after hours at 800-841-1255, Psychiatric Emergency Services at 512-454-3521, call 911, or go directly to the nearest hospital or call 911.

 

Fees are part of your therapy.  Payment of your fee by personal check, cash, or credit/debit card is due at each session.  Fees are as follows: Initial Assessment $150.00, Individual $125, Couple or Family $125, Group $35 for 60 minutes, and $50 for 80 minutes.  A sliding fee scale will be available to those in financial need.  Returned checks are subject to a $25.00 dollar fee. After hours calls, emergencies, or outside of the office therapy will be billed at the rate of your regular fee plus 25 %, billed by the quarter-hour.  Reading, reviewing or responding to lengthy emails or phone calls longer than ten minutes outside of your scheduled session will be billed at $125 per hour billed by the quarter-hour. This includes any required travel time. 

 

I do not normally represent clients in court or court cases. If you reasonably expect that your counseling will result in court-related issues, it is highly recommended that you seek out a counselor familiar with and comfortable with testifying and court work.  Please discuss this with me. For those that I do decide to represent, my fees are as follows: legal evaluations and or written professional opinions or summaries for legal proceedings, consultations with your attorney or an opposing attorney, calls or emails relating to your case or conflict as well as preparation for court will be billed at $400 per hour.  A fee of $500 per hour will be charged for court testimony billed by the quarter-hour.  A non-refundable retainer of $1000 will be required prior to beginning any court work.  Once the retainer is exhausted it will need to be replenished in $1000 increments.  If I am required to block off time for court, there will be a fee of $400 per hour.  If I am notified within 24 hours prior to the date that court has been postponed or delayed, I may waive the fee for any hour that I am able to fill.  If I am required to travel, all expenses will be incurred by the client. Please note that these may not be covered by insurance.

 

For clients who chose to file insurance claims, I will provide a statement that you can use to file with your insurance company. I do not file insurance claims.

 

You and your therapist can discuss any questions or concerns that you may have regarding this information before proceeding.  By signing below, you are indicating that you have read and understood this contract and that any questions you may have had about this statement have been answered to your satisfaction. This contract supersedes and renders void any previous contracts or agreements, written or verbal, between the undersigned and Jim Colbert, LPC. If you would like a copy for your records, you may download and print a copy or your therapist will be happy to make a copy for you for your records.

 

 

_______________________________­­­­_____________________________          _____________________________

Client Signature or Legal Guardian                                                                                Date

 

____________________________________________________________          _____________________________

Printed Name                                            Relationship to Client                                               Area Code & Phone number

 

______________________________________________________________________________________________

Address

 

_____________________________________________________________        _____________________________

Name of Client if Different from above                                                                                    DOB

 

______________________________________________­­­­_______________         ____________________________

Counselor's Signature                                                                                                        Date

 

 

Please provide the credit or debit card information requested below, which will be maintained in confidence and used solely for the purpose of charging for charges incurred during your therapy. Cards will be run for only the instances checked below. No show or cancellation fees are explicitly authorized. I understand that this form is valid unless I cancel the authorization through written notice to the health care provider.

 

I authorize my therapist to keep my signature on file and to charge my account for:

 

• This visit only for $________.

• Each session at a private pay rate of $_________

• Unpaid balances, fees, or adjustments not to exceed _________.

• $1000 court work retainer

 

Client’s name: ____________________________________________________

 

Card Holder’s name        _____________________________________________________

 

City ___________________________  Zip  ____________ 

 

VISA       MasterCard     Other             Account # _____________________________________

  

Security Code (the 3 digit code on the back of the card)  __________

 

Signature ___________________________________     Exp. Date _______ / ________