Jirvana - 2021 Pricing

Matt Misuraca, LMFT &

Jirvana Workshops

Pricing

Individual Therapy - $150 per hour

Couples & Family Therapy - $150 per hour

Jirvana Weekly Workshops - $65 for 2 hours

Jirvana Individual Workshops - $980 for weekend

Couples Workshop - $1350
Please initial here:

Client Information
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name (First, Last):

First NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My Billing Address is different from my Mailing Address:
Billing Address (if different from above):

Street Address

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CityState

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Home Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Number:
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Number:
Please enter a valid phone number.Format: (000) 000-0000.
What number can I leave a confidential voicemail or text message to you on?
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
How did you hear about me? (Friend, online, google, etc...)
If it was a friend, may I contact to thank them for referring me?
Your Employer:
Employer Phone Number:
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Employer Address:

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Person Responsible for your bill:
Please provide information on your Medical doctors:
Are you under the care of a psychiatrist? If SO, who?
Do you take any medications? Please list:
Please provide information on who we should contact in case of an emergency:
Emergency Contact:
Relationship:
Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

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Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.

MATT MISURACA, MA, LMFT OFFICE POLICIES

PAYMENT
Payment is due at the end of each session unless other arrangements are made. Please notify me if any problem arises during the course of your therapy regarding your ability to make timely payment. My charge is $_150.00_per individual session. Or $_150.00_ Family session. Sessions are 50 minutes leaving time for charting.

CONFIDENTIALITY
All information disclosed within sessions, including that of minors, is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. Disclosure may be required in the following circumstances:
- When there is a reasonable suspicion of abuse to a child, dependent or elder adult
- When the client communicates a serious threat of bodily injury to others
- When the therapist has a reasonable belief that the client may be a danger to themselves, others or property of others
- When disclosure is otherwise required by law
I may receive regular professional consultation. In such cases, neither your name nor any identifying information about you is revealed.

CANCELLED/ MISSED APPOINTMENTS
A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than twenty-four (24) hours' notice, you will be billed according to the scheduled fee.

ADDRESS CHANGES
Please advise me if you change your address, telephone number or place of employment or psychiatrist.

EMERGENCY TREATMENT
I usually return calls within 24 hours. If this is a life-threatening emergency, please call 911. When I am out of town or otherwise unavailable, Upon Request, a qualified professional will cover for me by checking my calls.

LITIGATION CHARGES/ Fee for Filling out Forms
If I am required to attend a deposition, hearing or other legal proceeding, you will be billed at $_200.00_ per hour for my time, with a 4 hour minimum, this includes preparation and travel time as well as the time I send at the legal proceeding.

I HAVE READ AND UNDERSTAND THESE OFFICE POLICIES
Name

First NameLast Name
Client Signature
Parent or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Matt Misuraca, MA, LMFT

Consent For Treatment

I, {namefirst130}, authorize and request that my therapist, Matt Misuraca, MA, LMFT, provide psychological examinations, assessment, interventions and / or diagnostic procedures that now or during the course of my care as a patient are advisable. The frequency and type of assessment and interventions will be decided between my therapist and me.

I understand that the purpose of these procedures will be explained to me per my request and are subject to my verbal agreement.

I understand that there is an expectation that I will benefit from this assessment and/or interventions but there is no guarantee that this will occur.

I understand that the maximum benefit will occur with consistent attendance and at times I may feel conflicted about my therapy, as the process can sometimes be uncomfortable. I have read and fully understand this consent for treatment form.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

MATT MISURACA, MA, LMFT

74- 133 El Paseo unit 11, Palm Desert, CA 92260 (760) 708-8253, Fax (760) 779-5600

MFC 53014

ACKNOWLEDGEMENT OF ELECTRONIC COMMUNICATION RISK

From time to time, clients and their therapists choose to communicate through email or text with their therapist. However, no communication online or by cell phone is ever truly and completely secure and confidential. Therefore, the following agreement is entered into between {namefirst130} & his/her therapist, Matt Misuraca, LMFT.

I, {namefirst130}, hereby acknowledge and understand that communication entered into with my therapist through email or by cell phone or any other online /electronic means is not necessarily confidential and private. If I choose to communicate with my therapist, Matt Misuraca, LMFT, by electronic means, I agree not to hold him responsible or legally liable for any discovery or disclosure that may be made via online communication and through no fault of his own. I understand that he has made every attempt to keep my information private and confidential (see W & I Code 5328 & HIPAA regulations) and has the following disclosure at the bottom of all of his emails to me:

Confidentiality Notice: This transmission and any documents accompanying this transmission may contain personal information subject to such privacy regulations as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and by Federal confidentiality rules (42 CFR Part 2). This information is intended only for the use of the individual to which it is addressed. This information is intended only for the use of the authorized individual named above. Such authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosures, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and so destruction/return of these documents can be arranged at no cost to unintended receiver.

This information may have been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). If this information includes any "patient health information," the Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Name

First NameLast Name
Name for Form:

First NameLast Name
Signed:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Email:
example@example.com

MATT MISURACA, MA LMFT #540203

JIRVANA Workshops

CREDIT CARD INFORMATION / AGREEMENT FORM

PAYMENT / AUTHORIZATION INFORMATION
Authorization:

I authorize Matt Misuraca, MA, LMFT and Jirvana Workshops to make the following charges to the credit card listed.

1. Fees for therapy/or workshops services rendered, per fee schedule provided by Matt Misuraca, MA, LMFT and Jirvana Workshops and/or agreed upon and documented.

2. Fee for No Show or Late Cancellations per the Psychotherapist/Client Agreement form.

3. Insurance co-pays due and/or deductible monies due.

* Credit Card information will be collected on our first session.
Patient Name:

First NameLast Name
Payment method
Name of Card Holder:
Card Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Card Holder Email Address:
example@example.com
Card Holder Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Print Name:
Date

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Should be Empty:

Rows	Not at All	A Little	Somewhat	A Lot
1. Nervousness or shakiness
2. Feeling sad or blue
3. Feeling hopeless about the future
4. Feeling everything is an effort
5. Feeling no interest in things
6. Your heart pounding or racing
7. Trouble sleeping
8. Feeling fearful or afraid
9. Difficulty at home
10. Difficulty socially
11. Difficulty at work or school

Rows	Strongly Agree	Agree	Disagree	Strongly Disagree
12. I feel good about myself
13. I can deal with my problems
14. I am able to accomplish the things I want
15. I have friends or family that I can count on for help

Client Information

For questions 1 through 16, please think about your experience in the past week:

Please answer the following questions only if this is your first time completing this questionnaire.