TOM EDWARDS, LCSW
I agree to pay Tom Edwards, LCSW, according to the fee scale below:
Diagnostic Interview/ Initial Consultation: $125
Individual Therapy 45-50 min: $100
Family Therapy 45-50 min: $100
Group Therapy 60 min: $50
Group Therapy 90 min: $75
Existing Patient Check In 30 min: $75
Extended Individual / Family Therapy 75-90 min: $150
Clinical Inventory: $150
Missed Appointment: $75
I certify that I am an authorized user of this card and that I will not dispute the payment, so long as the payment corresponds to the terms agreed to in this form. I understand that I may withdraw from this agreement or change options at any time with proper notification. All information is kept private and is available only to Tom Edwards and/or office staff trained re: HIPPA.
AUTHORIZATION FOR TREATMENT OF MINORS/DEPENDENTS
In Tennessee, a person who is 16 years or older can legally give his/her consent receive health service ( TCA 33-6-101). Individuals under the age of 16 years are legal minors and must have a parent or legal guardian authorize professional services.
I certify that I am the parent or legal guardian of the patient above, who is a minor or dependent under the laws of the state of Tennessee. I authorize Tom Edwards, LCSW, to provide psychological treatment to this patient. I further authorize that I have legal standing to involve this patient in treatment and am responsible for communicating any limitations to that as well as any elements of a parenting plan, if applicable, that would affect the involvement.
Such treatment may include, but is not limited to, individual psychotherapy, group psychotherapy, family therapy, clinical inventories and questionnaires, and/or other specialized procedures, which are generally accepted in the field of clinical social work.
ADULT PATIENT AUTHORIZATION FOR TREATMENT
Being of legal age to grant consent, I authorize Tom Edwards, LCSW to provide my psychological treatment. I understand that this treatment may include, but is not limited to, individual psychotherapy, group psychotherapy, family therapy, clinical inventories, and/or other specialized procedures, which are generally accepted in the field of clinical social work.
I/ We understand and agree to the following as it relates to the treatment of the above- named patient:
That entering into psychological treatment is a voluntary activity. Although parents may initiate therapy for their children, there is always the choice to participate.
That therapy is built on honest disclosure by all involved.
That children and adolescents, like adults, have the right to confidentiality. Tom Edwards, LCSW will not disclose the details of a patient's therapy without that patient's consent, unless the safety of that patient or others is thought to be at risk. Exceptions to this include suspected abuse or neglect that has not been reported. Of course, the patient is free to disclose as he or she sees fit.That Tom Edwards, LCSW will, from time to time, discuss clinical issues via telephone and/or internet video conferencing applications. It is understood that these communications may not be secure.
That Tom Edwards, LCSW does not provide emergency psychiatric care. I/Wehave the responsibility to deal with emergency situations by either calling 911, proceeding to an emergency room, or putting into place some other designated emergency plan. I/We understand that I/We will have access to an answering service to address after-hours situations.
That should therapy not lead to the desired outcome, I/ We will have the responsibility to communicate that concern to Tom Edwards, LCSW. I/ We may be given information about other treatment options and are welcome to pursue them at any time.
SIGNATURES BELOW INDICATE REVIEW, AGREEMENT, AND CONSENT TO ALL ABOVE POLICIES.