CONFIDENTIALITY: We will legally abide by the laws and Certifying Board regulations concerning patient’s rights to confidentiality. Information released from this office must have informed consent signed by the patient before providing information to other persons. Exceptions to this rule only apply in cases of child abuse, threats of self-demise or violence, or subpoena and court order.

EMERGENCY: As we are not staffed 24 hours a day, in the event of an after hours crisis, we encourage you to visit the emergency room of the nearest hospital where you will receive prompt attention, especially in cases involving medication. Please also leave a message at our office and page number.

PAYMENT: Payment is due at the end of each session.

Fees are based on 50 minute sessions at $140.00, or agreed sliding fee of _____, per session or with pre-authorized insurance (authorization #_________________) , a co-pay of ___________ as agreed by __________________. These fees include family, marital, group or individual sessions.

B) A different fee schedule exists for longer evaluations, testing, expert witness fees, consultation and test interpretation.

All reports are billed at a minimum $100.00 based on $200.00 per hour.

Telephone calls are billed at $2.00 a minute in blocks of 5 minutes.

Medical insurance may defray some of the cost for the sessions if your insurance company covers the cost of the sessions. It is the patient’s obligation to check with their insurance company to determine if our services are covered. It is the responsibility of the patient to file their own insurance claims to have the premiums sent directly to them as the patient agrees to pay the therapist at the time of the session. It is important to understand that this agreement is with you as the patient and not with the insurance company. Delinquent fees are subject to collection by an appropriate agency if not paid within 90 days. Please contact the office if you have difficulty in making payment, as a sliding fee scale based on income is available for negotiation.

CANCELLATION: Cancellations must be made at least 24 hours prior to the time of the scheduled appointment or the full amount will be charged to your account, except in the cases of obvious emergencies. Excessive cancellations will result in termination of treatment.

COUNSELOR NOTIFICATION: The patient has received a biographical sketch of the Dr. Brown’s credentials and has been notified of his qualifications and licensure.

CONSENT TO TREAT: The patient has been made aware and consents to the nature, structure and limitations of the treatment, and the understands the limitations or exceptions to confidentiality within the family or marriage when in family or marital counseling.

PLEASE INITIAL IF REQUESTING SPIRITUAL/BIBLICAL COUNSELING: ________/__________

I fully understand and agree to the patient/therapist agreement with Dr. Kenneth N. Brown, LMFT.

Date: __________
Patient/Guardian: ________________________/ ______________________________