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. This fee cannot be billed to your insurance. Services may be terminated as a result of missed appointments or late cancellations.
Our full Notice of Privacy Practices is available in hardcopy in the office and/or can be emailed to you at your request.
Telehealth is live two way audio and video electronic communications that allow therapist and client to meet outside of a physical office setting. I understand that none of the telehealth sessions are to be recorded or photographed by either therapist or client.
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.
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.