The therapeutic relationship is unique in that it is highly personal and, at the same time, a contractual agreement.
We do not provide an emergency on call service. If you are in crisis, call 911 or go to the nearest emergency room.
If an appointment is not cancelled at least 24 hours in advance, you will be charged the full session fee. Insurance does not cover this fee. Services may be terminated as a result of missed appointments or late cancellations.
Our full Notice of Privacy Practices is available on our website and can be emailed to you at your request.
You understand that there will be no recording of telehealth sessions by either party, neither client nor therapist. You understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
Make sure you know your insurance plan and what it will cover. You accept responsibility for payment of any patient portion charges and any balance due for charges not covered by your insurance policy at the time of service. It is your responsibility to notify us of insurance changes at least 24 hours prior to your appointment.
The completion of documents for school, employment, court, disability claims, the Family Medical Leave Act (FMLA), or other purposes goes beyond routine treatment. It cannot be billed to your insurance company. It is our policy to charge $25 per document for the completion of all forms and/or letters. Payment is due at the time of request; your request will be completed within 5 business days.
By signing this document, you are consenting to engage in therapy and agree to all policies outlined above. You authorize assignment and payment of benefits to Just Breathe Connecticut LLC for services rendered. You consent to the use and disclosure of protected health information about you for the purposes of treatment, payment and healthcare operations.