Informed Consent

This information sheet is to familiarize you with the policies affecting issues that frequently arise over the course of treatment. The ethical cannons of my profession demand that I respect the dignity and integrity of those who seek my help regardless of race, religion, gender, ethnicity, age, disability, or source of payment. Your signature on this document will indicate that you have read and understand it and agree to its provisions. I am willing to discuss my office policies with you at any time.

1. If you are an adult, anything you say in the context of therapy is privileged with these exceptions:
 A) If you are behaving in a way that poses a threat to the physical well-being of yourself or another person, privilege is waived. I am bound by law to contact the person(s) involved, and warn them of possible dangers.
 B) If a parent or guardian is suspected of child abuse, Ohio State Law mandates that I report his/her concerns to the appropriate authorities.
 C) If you are using confidentiality as a means of avoiding legal punishment, privilege is waived. All actions taken under these provisions will be discussed with you fully, and in advance, whenever possible.

2. Parents or guardians of minors are entitled to information communicated by their children in therapy. However, ethics require me to communicate such information only in ways that will be helpful to enhancing family relationships and not jeopardize the relationship between the minor and myself.
3. Regarding divorce or pending divorce, it is the policy of this office that financial responsibility for the account belongs to the parent/guardian initiating treatment.
4. When asked to send records to or request records from health care providers, you will be asked to sign a “release of information” form, without which I cannot send records.
5. In this office, the staff is comprised of a licensed professional clinical counselor and administrative assistant. You have the right to know the professional training and background of the staff members.

1. The standard fee for the initial assessment is $175.00.
2. The standard fee for individual therapy sessions is $140.00 per 55-60 minute sessions and $100.00 for 25-30 minute session. Please speak with me if a sliding scale is necessary.
3. Payment must be made at the time of the session by cash, check, credit card, or venmo.
4. I understand that evaluation and treatment can be expensive and I encourage you to feel free to discuss any aspects of the billing at any time.
5. Phone contact made by the client or on behalf of the client that exceeds 10 minutes will be charged $40.00 per 15 minute increment.
6. Any reports or letters written on behalf of the client will be charged $150.00 per 60 minute preparation time.

The following credit card information will be kept confidential and will only be used in the event that payment is not made on the date of service, an appointment is cancelled with less than 24 hour notice (except in the case of an emergency), or the client authorizes the credit card to be used as the method of payment.

Note: Your signature is an acknowledgment of understanding about the information detailed on this form.

1. I require a 24-hour advance notice if you cannot keep the appointment. Otherwise, you will be charged for the missed session
2. Routine calls for information and appointment scheduling will be handled during the normal workday. Confidential messages may be left on my office numbers at any time
3. Should you or a family member be experiencing an emergency, please call 911 or go to the nearest emergency room

- I agree and consent to participate in mental health services.
- I understand that I am consenting and agreeing only to those services that the therapist is qualified to provide within the scope of the provider’s license, certification, and training.
- I understand that no promises have been made to me as to results of any treatment of any procedures provided

If the patient is under the age of eighteen, I attest that I have legal custody of this child and am therefore allowed to initiate and consent for treatment and I agree to assume financial responsibility for this treatment.

Thank you, Robert Schuppel, LLC