This form is confidential and encrypted for HIPPA compliance.
1. Fees for each individual client, family or couple are:
a. 55-min. sessions are $170.00
b. 75-min. sessions are $225.00
c. 90-min. sessions are $270.00
Payment is due at the time of therapy. Cash, credit card or checks are all accepted. If you would like to pay for multiple sessions up front, this is an option as well.
Therapy sessions are typically scheduled on a weekly basis but together we will determine how often to schedule sessions according to your personal schedule, budget, and therapeutic goals.
A receipt for the therapy session can be provided on request so that you may file a claim for reimbursement from your insurance plan as this office only receives payment directly from the client.
2. No show/late cancellation policy. Charges will be made to you for missed appointments that
are not canceled and for those that are canceled with less than 48 hours notice.
3. The no show/late cancellation fee is the same as a session and is not covered by insurance or managed care companies. Each client gets one and only one missed session with no fee due to illness or incident “out of his/her control”, but after one, he/she will be charged the full fee for subsequent missed sessions regardless of the reason.
4. The client is responsible for all fees. Should your account become delinquent, you understand that you are responsible for all legal fees, court costs, and collection charges involved as a result of any delinquency in your account. If account payments are delinquent, they will be either reported to the credit bureau or to a collector.
5. You may call me at (512) 422-1712 and leave a message that will be returned within 24 hours.
If you have an emergency, please contact 472-HELP or 911. Phone calls over 10 minutes long are charged at the same rate as therapy sessions. If emergency calls begin to occur on a regular basis, this generally indicates that office appointments need to be scheduled more often.
6. Email communication and texting are not considered confidential mediums. This is instated to both protect your privacy and to remain in compliance with HIPAA standards.
7. Confidentiality: Any communications between you and the therapist and any records maintained by the therapist are confidential and may be disclosed only under certain conditions.
CINDY AUSTIN, MS, LPC
4500 Alamosa Drive
Austin, Texas 78759
Should you wish to disclose confidential information about yourself to someone else, you may sign a written release. There are limits to confidentiality which include, but are not limited to: (a) records that can be subpoenaed in lawsuits regarding litigation as to the
mental condition of the client, child custody suits, and malpractice claims, (b) the exceptions to confidentiality include the therapists duty to warn if there is a serious danger to the client or if the client threatens to harm a readily identifiable person and (c) also there is exception when there is threat of physical or sexual abuse of a child, elderly person or vulnerable adult person.
Texas has mandatory laws requiring a person to be reported if there is cause to believe a child has been abused or neglected.
a. I will not release records to a client that requests to see them when I professionally
believe that by doing so the client would not benefit or in fact may be harmed.
b. On an as needed basis, I share progress notes with other professionals for review and
feedback in order to help best assist you with your therapeutic goals.