Sue Ann Edwards, M.A., M.F.T., R.P.T.S.

License MFC29418

12520 High Bluff Drive #358 (858) 755-3636

San Diego, CA 92130 fax (858) 755-3615

Contract for Psychotherapeutic Services

Consent for Treatment Form

Welcome to my therapy practice. This document contains important information about my

professional services and business policies. Please read it carefully and jot down any questions so that
we can discuss them. When you sign this document, it will represent an agreement between us.

THE THERAPY PROCESS

Psychotherapy is not easily described in general statements. It varies depending on the personalities of
the therapist and client, and the particular problems you bring forward. There are many different
methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a
medical doctor visit. Instead, it calls for a very active effort on the client’s. In order for the therapy to be
most successful, the client will have to work on things we talk about during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects
of life, uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness may
be experienced. On the other hand, psychotherapy has also been shown to have benefits for people
who go through it. Therapy often leads to better relationships, solutions to specific problems, and
significant reductions in feelings of distress. But there are no guarantees of what you will experience.
When working with children, behavioral symptoms often increase before positive changes occur.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be
able to offer you some first impressions of what our work will include if you decide to continue with
therapy. You should evaluate this information along with your own opinions of whether you feel
comfortable working with me. Therapy involves a large commitment of time, money, and energy, so
you should be very careful about the therapist you select. If you have questions about my procedures,
we should discuss them whenever they arise.

CONFIDENTIALITY
In general, the privacy of all communications between a client and a therapist is protected by law, and
I can only release information about our work to others with your written permission. But there are a
few exceptions.
In most legal proceedings, you have the right to prevent me from providing any information about
your treatment. In some proceedings involving child custody and those in which your emotional
condition is an important issue, a judge may order my testimony.
There are some situations in which I am legally obligated to take action to protect others from harm,
even if I have to reveal some information about a client’s treatment. For example, if I believe that a
child, elderly person, or disabled person is being abused, I must file a report with the appropriate state
agency.
If I believe that a client is threatening serious bodily harm to another, I am required to take protective
actions. These actions may include notifying the potential victim, contacting the police, or seeking
hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek
hospitalization for him/her or to contact family members or others who can help provide protection.
These situations have rarely occurred in my practice. If a similar situation occurs, I will make every
effort to fully discuss it with you before taking any action.
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I
make every effort to avoid revealing the identity of my client. The consultant is also legally bound to
keep the information confidential. If you don’t object, I will not tell you about these consultations
unless I feel that it is important to our work together.
While this written summary of exceptions to confidentiality should prove helpful in informing you
about potential problems, it is important that we discuss any questions or concerns that you have. I
will be happy to discuss these issues with you if you need specific advice, but formal legal advice may
be needed because the laws governing confidentiality are quite complex, and I am not an attorney.

PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to
receive a copy of your records, or I can prepare a summary for you instead. Because these are
professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to
see your records, I recommend that you review them in my presence so that we can discuss them.

PROFESSIONAL FEES
My hourly fee is $225.00. This fee will be charged for each standard 50 minute psychotherapy session.
Sessions that are longer than the standard 50 minute treatment hour will be prorated to the nearest
quarter hour. In addition to weekly appointments, I charge this amount for other professional services,
though I will break down the hourly cost if I work for periods of less than one hour. Other services
include report writing, consultation with other professionals, telephone conversations lasting longer
than 10 minutes, attendance at meetings with other professionals you have authorized (e.g. school
Student Study Team or Individualized Educational Plan meeting, conjoint therapy), preparation of
records or treatment summaries, and the time spent performing any other service you may request of
me. Insurance plans typically do not reimburse you for these charges.
If you become involved in legal proceedings that require my participation, you will be expected to pay
for my professional time even if I am called to testify by another party. Because of the difficulty of legal
involvement, I charge $360.00 per hour for consultations, communications with attorneys or mediators,
preparation for and attendance at any legal proceeding.
You will be expected to pay for each session at the time it is held. If your account has not been paid for
more than 60 days and arrangements for payment have not been agreed upon, I have the option of
using legal means to secure payment. This may involve hiring a collection agency or going through
small claims court. If such legal action is necessary, its costs will be included in the claim. In most
collection situations, the only information I release regarding a client’s treatment is their name, the
nature of services provided, and amount due.

MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right
to examine your treatment records. It is my policy to request an agreement from parents that they
agree to give up access to your records. If they agree, I will provide them only with general
information about our work together, unless I feel there is a high risk that you will seriously harm
yourself or someone else. In this case, I will notify them of my concern. Before giving them any
information, I will discuss the matter with you, if possible, and do my best to handle any objections
you may have with what I am prepared to discuss.
OFFICE POLICIES

Payment for Services: You are expected to pay for services at the time they are rendered. Please
notify me if any problem arises regarding your ability to make timely payment. A charge of $25 is
assessed for any checks returned from your bank. I do not “split accounts” or send dual statements; I
request that one party be responsible for a child or family account. If expenses are to be shared by
agreement between two parties, they may do so between themselves.
Insurance Reimbursement: I do not bill insurance companies nor do I accept payment from them.
Clients who carry insurance are responsible for their own insurance reimbursement. However, I will
provide you with the appropriate information and my billing service (see below) will assist you.
Billing Questions: All questions regarding billing should be directed to Linda Saucier at
Griebel Billing Services at (619) 224-6343; her fax number is (619) 222-0788. Please retain copies of
your monthly statements as your personal financial records. Requests for additional statements or
summaries will require an additional accounting fee.
Cancellation: Since an appointment reserves time specifically for you, a minimum of 24-hours notice
is required for rescheduling or cancellation of an appointment. The full fee will be charged for sessions
missed without such notification. Insurance companies do not reimburse missed appointments.
Office Hours & Telephone Contact: I am often not immediately available by telephone. While I am
usually in my office between 10:00 am and 6:00 pm Monday through Friday, I likely will not answer
the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail
that I monitor frequently. I will make every effort to return your call within 48 hours, with the
exception of weekends and holidays.
Emergency Procedure: In case of an emergency, please call 9-1-1, call the San Diego Crisis Center at
1-800-479-3339, contact your personal physician or proceed to the nearest emergency facility
immediately; do not wait to contact me by telephone.
Termination: You have the right to end therapy at any time without any moral, legal, or financial
obligations other than those already accrued. I ask that you contact me by phone if you make such a
decision without consulting with me.
I have the right to terminate therapy with you under the following conditions:
a) When I believe that therapy is no longer beneficial to you.
b) When I believe that you will be better served by another professional. If possible, I will assist
you in finding another qualified mental health professional.
c) When you have not paid for the last two sessions, unless prior arrangements have been made.
d) When you fail to show up for your last two therapy sessions without 24-hour notice.
If any of these situations apply, I will inform you of my decision and I will give you the names of other
therapists for your future counseling needs.

CONSENT
Your signature below indicates that you have read the information in this document and agree to abide
by its terms during our professional relationship.

Date ______________ Client’s Signature ____________________________________________________

Date ______________ Responsible Party’s Signature _________________________________________

FOR PARENTS OF CHILD CLIENTS

1. When working with an individual child, I respect his/her right to confidentiality. I will consult
with you regularly about your child’s progress. Both parents are entitled to know the nature and
progress of the child’s therapeutic services. However, I recommend you not ask your children
direct questions about their therapy experiences so as not to inhibit their participation or progress.
2. I will often speak with parents regarding their child and sometimes involve parents in their child’s
treatment. This should not be understood to mean that the parents are clients.
3. If I am seeing your child in individual sessions, please tell me prior to the beginning of the session
whether there have been any unusual events since our last session or issues of concern you wish to
discuss. This interchange must be brief so as not to interfere with the child’s therapy session. If
more time is needed, please call for a separate appointment or request a telephone consultation.
4. Please do not leave the office while your child is in session. Some children need to know that their
parent is present for them in the waiting room and sometimes I involve the parent in a session.
Your child may also need you to accompany them to the restroom. Children must be accompanied
by an adult at all time while in the office complex. Sessions are typically 45-50 minutes in length.
5. Children should not be left unsupervised at any time and are not allowed to leave my office
without adult supervision. Also, other professionals are doing work in adjoining facilities so I ask
that my clients be respectful of their need for quiet and privacy. Food is discouraged in the office.
6. Since I often use art and play materials in therapy with children, please dress your child in clothing
appropriate for messy play.
7. If your child may be ill, please cancel your appointment for the health of your child and others.

Consent to Treat Minor

I _____________________________________, as parent/guardian of minor child named

_____________________________________, authorize and request Sue Ann Edwards, M.F.T. to carry
out psychological examinations, diagnostic procedures, and/or treatments that are advisable now or
during the course of his/her care as a patient. I understand that the purpose of any procedure will be
explained to me and be subject to my agreement. I have read and fully understand this consent form.

Date ______________ Parent/Guardian Signature ____________________________________________

Date ______________ Parent/Guardian Signature ____________________________________________

Involvement in Court Proceedings Waiver

The undersigned will neither individually nor jointly involve Sue Ann Edwards, M.F.T. in any
litigation. The undersigned will neither request nor require Sue Ann Edwards, M.F.T. provide
testimony in court. The reason for this is so that treatment is not compromised, the therapeutic
relationship with the family is maintained, and the child experiences their therapist in a clear,
consistent, therapeutic role and not as an assessor or detective. If the services of a mental health
professional are desired for court purposes, the services of a separate professional must be enlisted.

Date ______________ Parent/Guardian Signature ____________________________________________

Date ______________ Parent/Guardian Signature ____________________________________________