THERAPY AGREEMENT
I understand that I am eligible to receive treatment in the form of individual therapy. The type and extent of service that I will receive will be collaboratively determined thorough discussion with me.
I understand that I am free to discontinue these services at any time without penalty or prejudice (with the exception of late cancellations/no shows as identified below).
I understand that this consent will remain in effect until such a time as I withdraw it via written consent or discontinue services with my therapist by informing them of my intent to do so.
ATTENDANCE
Individual therapy sessions are between 50 and 60 minutes in duration. Session frequency can vary over the treatment period, depending on the specific therapy goal and the progression of treatment.
I agree to inform my therapist 24 hours prior to our appointment time if I need to cancel or change an appointment time. I understand that unexcused no shows or late cancellations will be automatically billed/charged at 50% of the total cost of the session booked.
FINANCIAL AGREEMENT
I hereby agree to pay all fees relating to services received as well as any third party collection and legal costs associated with any recovery of amount outstanding should they occur. I acknowledge that my session fee is $149 per one hour online video/audio therapy and telephone consultations (excluding initial telephone, in-take, or scheduling). Other billable services, such as report writing, professional letters, form completion, and review of written records from other specialists are billed at the same rate.
I understand that a retainer amount may be collected to hold an appointment or prepare for an assessment and that additional charges will be added to that retainer to reach previously discussed or agreed upon fee for service and fees shall never exceed the agreed upon amount. Payment is required at the beginning of each appointment and I will receive a receipt upon payment. I acknowledge that, should I be unable to remit payment for a session, it will not be possible to book another session until such a time as I have paid all outstanding fees.
RISKS AND BENEFITS
I understand that while psychotherapy may provide significant benefits based on empirical evidence, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recollection of troubling memories.
RIGHTS AND RESPONSIBILITIES
I have a right to be treated with respect, dignity, and without discrimination regardless my age, gender, mental and physical status, sexual orientation, race, belief system or ethnic background. I can expect from my therapist to make their best effort to conduct therapy as competently as possible. I have a right to ask questions at any time, be informed by my therapist as to their qualifications, areas of specializations and limitations, and the code of ethics which they follow. I have a right to be advised as to the limits of therapeutic service, discuss my treatment with others. I understand that I may stop treatment at any time. I understand that I have a right to view my file notes at any time and to know what is being recorded about me.
心理咨询协议
我知道我将接受个人心理咨询。我将得到的服务的类型和范围将与咨询师协商决定。本人明白本人可随时终止上述服务，不受任何惩罚或损害(迟到取消/缺席(见下文)除外)。我明白，这份同意书将继续有效，直到我书面撤回，或告知咨询师我中止心理咨询服务的意愿。
出席
个人咨询时间为50至60分钟，每次咨询的频率会因人而异，取决于具体的治疗目标和治疗进展。如果我需要取消或更改预约时间，我同意在预约时间前24小时通知相关人员。本人明白在24小时内无故取消或延迟预约将自动生效收费为所预订咨询总费用的50% 。
财务协议
我在此同意支付所有有关服务的费用，以及任何第三方收集和法律费用与任何未偿还的金额。本人知悉，除非经由经济活动组织或其他合约协议涵盖或另有指明，否则本人每小时的会诊费用为每小时$149，包括线上视听及电话咨询(不包括行政类事宜)。其他计费服务，如报告撰写、专业信函、表格填写和其他专业书面记录，也以同样的标准计费。本人知悉Megan Chang可以收取预约金额作为预约或专业测试的准备金，而预约金额将会加收额外费用，以达到先前讨论或议定的服务费，而服务费不得超过议定的金额。每次咨询开始时都需要先付款，收到款项后提供收据。本人知悉，如有欠款，将不能预约下一次咨询时间，直到全部费用被付清。
潜在风险
我明白，虽然心理治疗可能会提供显着的好处，基于经验证明，它也可能构成风险。心理治疗可能会引起不舒服的想法和感觉，或者可能导致负面记忆的回忆。
权利和责任
我有权受到尊重，有尊严，不受歧视，不论我的年龄，性别，身心状况，性取向，种族，信仰体系或民族背景。我可以预期我的治疗师尽最大努力尽可能地进行治疗。我有权在任何时候提出问题。若我提问，我的治疗师有义务告诉我他们的资质，专业领域和限制，以及他们遵循的道德准则。我有权被告知咨询服务的极限，与他人讨论我的咨询。我知道我可能随时停止咨询。我明白，我有权在任何时候查看我的档案记录，并了解有关我的记录。
我明白，我有责任为我的治疗设定治疗目标，并在需要时对它们进行审查。我会与我的治疗师合作，评估治疗过程，并努力实现我自己确定的目标。