Jirvana - 2024 Pricing

Matt Misuraca, LMFT &

Jirvana Workshops

Pricing

Individual Therapy - $180 per 50 min

Couples & Family Therapy - $180 per 50 min

Jirvana Weekly Workshops - $75 for 2 hours

Jirvana Individual Workshop Weekend - $1150 for weekend

Jirvana Couples Intensive - $1880 2 day
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Client Information
Date:*

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Name (First, Last):*

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Mailing Address:*

Street Address

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My Billing Address is different from my Mailing Address:

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Billing Address (if different from above):

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Home Number:*
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Work Number:
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Mobile Number:
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What number can I leave a confidential voicemail or text message to you on?*
Date of Birth:*

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Date
Email:*
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How did you hear about me? (Friend, online, google, etc...)
If it was a friend, may I contact to thank them for referring me?

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Your Employer:
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Person Responsible for your bill:
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Are you under the care of a psychiatrist? If SO, who?
Do you take any medications? Please list:
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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 $_180.00_per individual or family session. Sessions are 50 minutes leaving time for charting. Groups are 2 hours and the fee for group is $75 per group.

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, or change of telephone number.

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. You may also call Telacare Emergency Crisis line 760-863-8632.

TERMINATION: You may discontinue therapy at any time. It is important to have a termination process in order to achieve some closure. If you, or I determine, you are no longer benefiting fitting from treatment, either of us may elect to initiate the discussion of your treatment alternatives i.e.: referral, change of treatment plan, or termination of therapy.

I HAVE READ AND UNDERSTAND THESE OFFICE POLICIES
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Client Signature*

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Parent or Guardian Signature

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Date

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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*

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Signature*

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Date*

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Date

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.
Name*

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Name for Form:

First NameLast Name
Signed:*

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Date:*

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Client Email:*
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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

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Name of Card Holder:
Card Holder Address:

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Card Holder Email Address:
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Card Holder Phone Number:
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Signature*

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Print Name:*
Date*

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Date

MATT MISURACA, MA, LMFT74- 133

El Paseo unit 11, Palm Desert, CA 92260 (760) 708-8253, Fax (760) 779-5600
Good Faith Estimate
Name for Form:*

First NameLast Name
Date*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis (if known):
Date of Birth:
Date of 1st session:

Services requested: Psycho Therapy

You are entitled to receive this good faith estimate of what the charges could be for psychotherapy services provided. While it is not possible for any psychotherapist to know, in advance, how many psychotherapy sessions maybe necessary or appropriate for any given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances and type and amount of services that are provided to you.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in his good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.

You have the right to initiate a dispute resolution process is the actual amount charged to you substantially exceeds the estimate charges stated in your good faith estimate (which means $400 dollars or more beyond the estimated charge).

The fee for a 50-minutes psychotherapy session (in person or via telehealth) is $180.00. Most clients will attend one psycho therapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case maybe more or less than once per week depending upon your needs.

Based on the fee of $180.00 per visit the following are the expected charges for psychotherapy services:

Number of weeks	Total estimate for 1 Session per week $180	Total estimate for 2 Session per week $360.00	Total estimate for 3 sessions per week $540.00
13 weeks of services	$2340	$4680	$7020
26 weeks of services	$4680	$9360	$14,040
39 weeks of services	$7020	$14,040	$21,060
52 weeks of services	$9360	$18,720	$28,080

This good faith estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specific number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services depends on your needs and what you agree to in consultation with me. You are entitled to disagree with any recommendations made to you concerning your treatment, you may discontinue treatment and anytime.

You are encouraged to speak to me at anytime about any questions you may have regarding your treatment plan or the information provided to you in this Good faith estimate.

Name for Form:

First NameLast Name
Signature*

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Date*

MonthDayYear
Date

MATT MISURACA, MA, LMFT74- 133

El Paseo unit 11, Palm Desert, CA 92260 (760) 708-8253, Fax (760) 779-5600
Litigation Limitation:

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be a legal proceeding (such as, but not limited to divorce, custody disputes, injuries, lawsuits, etc.) Neither you (client) nor your attorney, nor anyone else acting on your half will call me to testify in court or any other proceeding. If notes or statements are required, clients will attend and come in person to an appointment, to review what will be released. Once client waves confidentiality to my notes, they are all potentially available to opposing counsel.

Court policy and court fees:

Please be advised that Matt Misuraca, LMFT (Therapist) at no time will make a recommendation or provide an opinion in regard to custody or any other court related matter.
I do not write letters to the court without subpoena.
I do not write letters for emotional support animals.
If court order is served and is legally requiring that therapist be present in person and or there is a request for records, the client’s consent will be requested before turning over confidential information. When obtaining this consent, the client will be told exactly what has been requested by the court, this includes a clients mental health history; client current mental health status and inclusive records, which may not be in the best interest of the client. The therapist/client relationship does not render the therapist as an advocate.
Please be advised should the therapist be ordered by court to write a letter to the court or be deposed the time she’ll be billed at $400 per hour including travel time.
Please be advised that should the therapist be court order to appear in court the fee stipulation is as follows:
$2000 per day plus $400 dollars per hour for travel to and from court with a one-day minimum.
$400 per hour for deposition with a minimum of four hours including travel time.
Therapist will NOT be on call at any time. Should case go to trial, therapist will be paid $400 per hour, to be paid in full for each day called, as well as an additional $1500 per day, as it hinders Therapist ability to be available to their other clients.
All court fees must be paid by cashiers check 14 days prior to the court date.

Should the court calendar the hearing for another date, Therapist must be reissued a court order with the new court hearing date.
Should the therapist be on vacation, the party initiating the court order must take responsible steps to avoid imposing undue burden or expense of a person subject to the subpoena

I agree to this Document:
Name

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	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

	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.

MATT MISURACA, MA, LMFT74- 133

Good Faith Estimate

MATT MISURACA, MA, LMFT74- 133