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Terms and Policy

DACS Therapy Consent, Policies & Agreement


BENEFITS/OUTCOMES:  The therapeutic process seeks to meet goals established by all persons involved, usually revolving around a specific complaint(s).  Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships.  The therapeutic process may reduce distress, enhance stress management, and increase one's ability to cope with problems related to work, family, personal, relational, etc.  Participating in therapy can lead to greater understanding of personal and relational goals and values.  This can increase relational harmony and lead to greater happiness.  Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided.  There can be no guarantees made regarding the ultimate outcome of therapy.

EXPECTATIONS: In order for clients to reach their therapeutic goals, it is essential they complete tasks assigned between sessions.  Therapy is not a quick fix.  It takes time and effort, and therefore, may move slower than your expectations.  During the therapy process, we identify goals, review progress, and modify the treatment plan as needed.

RISKS:  In working to achieve therapeutic benefits, clients must take action to achieve desired results.  Although change is inevitable, it can be uncomfortable at times.  Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions.  Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended.  We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.


Intake Phase - During the first session, therapeutic process, structure, policies and procedures will be discussed.  We will also explore your experiences surrounding the presenting problem(s). 

Assessment Phase - The initial evaluation may last 2-4 sessions.  During this assessment phase, I will be getting to know you.  I will ask questions to gain an understanding of your worldview, strengths, concerns, needs, relationship dynamics, etc.  During this relationship building process, I will be gathering a lot of information to aid in the therapeutic approach best suited for your needs and goals.  If it is determined that I am not the best fit for your therapeutic needs, I will provide referrals for more appropriate treatment.  

Goal Development/Treatment Planning - After gathering background information, we will collaborative identify your therapeutic goals.  If therapy is court ordered, goals will encompass your goals and court ordered treatment goals, based on documentation from the court (please provide any court documents).  Once each goal is reached, we will sign off on each goal and you will receive a copy.   

Intervention Phase - This phase occurs anywhere from session two until graduation/discharge/termination.  Each client must actively participate in therapy sessions, utilize solutions discussed, and complete assignments between sessions.  Progress will be reviewed and goals adjusted as needed.   

Graduation/Discharge/Termination - As you progress and get closer to completing goals, we will collaboratively discuss a transition plan for graduation/discharge/termination.

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for 45-53 minutes depending upon the nature of the presenting challenges and insurance authorizations.  It is difficult to initially predict how many sessions will be needed.  We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.  

APPOINTMENTS AND CANCELLATIONS: You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment within 24 hours of the scheduled appointment time.  IF an appointment can be rescheduled and kept within the same business week, there will be no charge.  If the session cannot be rescheduled within the same business week, an $85 charge will apply.  Sessions cancelled within 4 hours of the scheduled appointment time are considered "NO SHOW" and will be billed the full amount of the session.  If you cancel or rescheduled more than once, we may re-evaluate your needs, desires, and motivations for treatment at this time.  Each insurance panel has a different policy on whether clinicians can charge for missed appointment/s.  Check your provider's policies regarding cancellations and/or no shows.

Psychotherapy is a uniquely personal service; therefore, consultations may be briefly interrupted.  I may periodically take time off for vacation, seminars, and/or become ill.  Attempts will be made to give adequate notice of these events.  If I am unable to contact you directly, a colleague may contact you to cancel or reschedule an appointment.  


Initial Session fee is $165.00 (or your insurance copay)  45-minute therapy session is $135.00 (or your insurance copay) and  53-minute sessions are $155.00 (or your insurance copay).

Payment is due at the time of service.  Acceptable forms of payment are: exact-amount cash, or credit/debit card.  In the event that a scheduled appointment time is missed or cancelled less than 24 hours, please refer to the "Appointments and Cancellations" policy above.  

The clinician reserves the right to terminate the counseling relationship if more than two sessions are missed without proper notification. 

The clinician charges his/her hourly rate in quarter hours for phone calls over 10 minutes in length, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care.  All costs for services outside of session will be billed. 

TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case.  In order to protect your confidentiality, I strongly suggest not being involved in the court.  If I get called into court by you or your attorney, you will be charged a fee of $2,000 per day plus $200 per hour for travel to and from the court (one hour minimum each way) and $350 per hour for preparation to include travel time, court time, preparing documents, etc.  

COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records, the cost is $2.00 per page.  Payment for your medical records will be due prior or upon receipt and can be picked up at the office.  Please allow at least 2 weeks to prepare medical records.  

PHONE CONTACTS AND EMERGENCIES:  Office hours are from 10:00 am - 6:00 PM, Monday through Thursday.  If you need to contact the clinician for any reason please call 713-302-6698, leave a voicemail, and a return call will be made within 24 hours during the business week.  In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255.  If either you or someone else is in danger of being harmed, dial 911. 


Anything said in therapy is confidential and may not be revealed to a third party without written authorization, except for the following limitations:

Child Abuse - Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc.  If you reveal information about child abuse or child neglect, I am required by law to report this to the appropriate authority.

Vulnerable Adult Abuse - Vulnerable adult abuse or neglect.  If information is revealed about vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.

Self-Harm: Threats, plans or attempts to harm oneself.  I am permitted to take steps to protect the client's safety, which may include disclosure of confidential information.

Harm to Others: Threats regarding harm to another person.  If you threaten bodily harm or death to another person, I am required by law to report this to the appropriate authority.

Court Orders & Legal Issued Subpoenas: If I receive a subpoena for your records, I will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information.  I will contact you twice by phone.  If I cannot get in touch with you by phone, I will send you written correspondence.  If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order.  Despite any attempts to contact you and keep your records confidential, I am required to comply with a court order. 

Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services.  I will discuss the information and/or documentation with you in session prior to sending it to the court. 

Written Request:  Clients must sign a release of information form before any information may be sent to a third party.  A summary of visits may be given in lieu of actual "psychotherapy/process notes", except if the third party is part of medical.  If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.    

Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the necessary documentation (i.e. your signature on the "Therapy Consent & Agreement" that covers the cancellation policy to your bank or credit card company should a dispute of a charge occur.  If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted. 

Couples Counseling & "No Secret" Policy: When working with couples, all laws of confidentiality exist.  I request that neither partner attempt to triangulate me into keeping a "secret" that is detrimental to couple's therapy goal.  If one partner requests that I keep a "secret" in confidence, I may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive.  

Dual Relationships & Public: Our relationship is strictly professional.  In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship).  If we run into each other in a public setting, I will not acknowledge you as this would jeopardize confidentiality.  If you were to acknowledge me, your confidentiality could be at risk.     

Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients.  If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality.  I cannot be held liable if someone identifies you as a client.  Posts and information on social media are meant to be educational and should not replace therapy.  Please do not contact me through any social media site or platform.  They are not confidential, nor are they monitored, and may become part of medical record.    

Electronic Communication: If you need to contact me outside of our sessions, please do so via phone.   Clients often use text or email as a convenient way to communicate in their personal lives.  However, texting introduces unique challenges into the therapist-client relationship.  Texting is not a substitute for sessions.  Texting is not confidential.  Phones can be lost or stolen.  DO NOT communicate sensitive information over text.  The identity of the person texting is unknown as someone else may have possession of the client's phone. 

Do not use e-mail for emergenciesE-mail is not confidential.  Having said this, there is a HIPAA compliant e-mail program accessible to you through your DACS client portal. In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room.  Additionally, e-mail is not a substitute for sessions.  If you need to be seen, please call to book an appointment.  Do not communicate sensitive medical or mental health information via email.  Furthermore, if you send email from a work computer, your employer has the legal right to read it.  E-mail is a part of your medical record.     

Sessions Outside the Office: From time to time, clients like to meet in an alternate location (i.e. their home, in public, or somewhere more conducive for them).  We may be able to accommodate this request, however, this can put your confidentiality at risk.   


YOUR INSURANCE COMPANY - By using insurance, I am required to give a mental health disorder diagnosis that goes in your medical record.  The clinical diagnosis is based on your current symptoms even though you may have been previously diagnosed.  We will discuss your diagnosis during session.  Your insurance company will know the times and dates of services provided.  They may request further information to authorize additional services regarding treatment.  

IMPORTANT: Some psychiatric diagnoses are not eligible for reimbursement (ie: marriage/couples therapy).  In the event of non-coverage or denial of payment, you will be responsible to pay for services provided.  Delee D'Arcy, MA, LPC, LMFT of D'Arcy & Associates Counseling Services, PLLC reserves the right to seek payment of unpaid balances by collection agency or legal recourse after reasonable notice to the client. 

PRE-AUTHORIZATION & REDUCED CONFIDENTIALITY- When visits are authorized, usually only a few sessions are granted at a time.  When these sessions are complete, we may need to justify the need for continued service, potentially causing a delay in treatment.  If insurance is requesting information for continued services, confidentiality cannot be guaranteed.  Sometimes, additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not met.    

POTENTIAL NEGATIVE IMPACTS OF A DIAGNOSIS- Insurance companies require clinicians to give a mental health diagnosis (i.e., "major depression" or "obsessive-compulsive disorder") for reimbursement.  Psychiatric diagnoses may negatively impact you in the following ways:

Denial of insurance when applying for disability or life insurance;  Company (mis)control of information when claims are processed;  Loss of confidentiality due to the increased number of persons handling claims;  Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record.  This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits.   A psychiatric diagnosis can be brought into a court case (ie: divorce court, family law, criminal, etc.).  

It is important that you're an informed consumer.  This allows you to take charge regarding your health and medical record.  At times, having a diagnosis can be helpful (ie: child needing extra services in the school system or a person being able to receive disability).  

Why Some Clinicians Do Not Take Insurance:  These involve enhanced quality of care and other advantages: 

You are in control of your care, including choosing your therapist, length of treatment, etc. Increased privacy and confidentiality (except for limits of confidentiality).   Not having a mental health disorder diagnosis on your medical record.   Consulting with me on non-psychiatric issues that are important to you that aren't billable by insurance, such as learning how to cope with life changes, gaining more effective communication techniques for your relationships, increasing personal insight, and developing healthy new skills.  


1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent.  I have discussed any questions that I have regarding this information with Delee D'Arcy, MA, LPC, LMFT.  My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent.  I authorize Delee D'Arcy, MA, LPC, LMFT to provide counseling services that are considered necessary and advisable.

2. I authorize the release of treatment and diagnosis information (as described in Part III, above) necessary to process bills for services to my insurance company, and request payment of benefits to Delee D'Arcy of D'Arcy & Associates Counseling Services, PLLC.  I acknowledge that I am financially responsible for payment whether or not covered by insurance.  I understand, in the event that fees are not covered by insurance, Delee D'Arcy, MA, LPC, LMFT of D'Arcy & Associates Counseling Services, PLLCmay utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney.

( Type Full Name )
Technology Assisted Counseling (TAC) Policies, Consent and Agreement

This form is in addition to the regular Therapy, Policies, Agreement and Consent Form and Notice of Privacy Practices for Protected Health Information commonly known as HIPAA.  You must sign both in order to participate in Technology Assisted Counseling (TAC) sessions.  TAC incorporates email, phone and video counseling.  Prior to engage in TAC an assessment/consultation will be done to assure that TAC is an appropriate form of counseling. This is to inform you about what you can expect regarding your participation in TAC counseling.   


1.  The benefits to TAC counseling are:

2.  The ability to expand your choice of service provider.  

3.  More convenient counseling options including location, time, no driving, etc.  

4.  Reduces the overall cost and time of therapy due to not having to drive to and from and office.  

5.  Ability to have real time monitoring and reduces the wait time for scheduling office appointments.  Increased availability of services to homebound clients. clients with limited mobility, and clients without convenient transportation options.  


It is important to note that there are limitations to TAC counseling that can affect the quality of the session(s). These limitations include but are not limited to the following:

1.  I cannot see you, your body language, or your non-verbal reactions to what we are discussing.  

2.  Due to technology limitations I may not hear all of what you are saying and may need to ask you to repeat things. 

3.  Technology might fail before or during the TAC counseling session.  

4.  Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.   

5.  To reduce the effect of these limitations, I may ask you to describe how you are feeling, thinking, and/or acting in more detail than I would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.


When I provide phone/video-counseling sessions, I will call you at our scheduled time or send you link for our secure and HIPAA compliant video session.  I expect that you are available at our scheduled time and are prepared, focused and engaged in the session.  I am calling you from a private location where I am the only person in the room.  You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality.  If you choose to be a in a place where there are people or others can hear you, I cannot be responsible for protecting your confidentiality.  Every effort MUST be made on your part to protect your own confidentiality.  I suggest you wear a headset to increase confidentiality and also increase sound quality of our sessions.  Please know that I cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally.  Please assure you reduce all possibilities of interruptions for the duration of our scheduled appointment.  

Please know that per best practices and ethical guidelines I can only practice in the state(s) I am licensed in.  That means wherever you reside I must be licensed.  You agree to inform me if your therapy location has changed or if you have relocated your domicile to a different jurisdiction.

Connection Loss:

During Phone Sessions: If we lose our phone connection during our session, I will call you back immediately.  Please also attempt to call me at 713-302-6698 if I cannot reach you. If we are unable to reach each other due to technological issues, I will attempt to call you -3- times.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, I will call you from an alternate number.  The number may show up as restricted or blocked please be sure to pick it up.  

During Video Sessions: If we lose our connection during a video session, I will call you to troubleshoot the reason we lost connection.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session. 

Recording of Sessions:

Please note that recording, screenshots, etc of any kind of any session is not be permitted and are grounds for termination of the client-therapist relationship. 

Payment for Services: 

Payments for services must be made prior to each session.  I will charge your card on file as payment is to be completed prior to our session. 

Cancellation Policy: 

If you must cancel or reschedule an appointment, 24-hour advanced notice is required, otherwise you will be held financially responsible.  Should you cancel or miss an appointment with notification less than 24 hours this will result in being charged the full fee for your missed appointment.  Cancellations must be communicated by phone, NOT via email or text.  If clients have more than 2 cancellations during the course of treatment/therapy the therapist and client will address the need for ongoing therapy.  Should a client express and wish and/or desire to continue a client may be asked to pre-pay for sessions when they are scheduled.  If the client cancels or misses the session with less than 24 hours notice and the session is pre-paid, this follows the cancelation guidelines and the payment will not be reimbursed for the missed or canceled session less than 24 hours.  Phone/video sessions should be treated as regular in office sessions.  If you are late getting on the phone, are unable to talk at our scheduled time, your battery has died and you are unable to access another confidential place to talk, or any other variable that would have you not be able to attend our session please know that you will be charged for the session.  Please make the necessary arrangements you need to be available and present for your session.  

Emergencies and Confidentiality: 

I will request an emergency contact for you to include the person's first and last name, relationship and phone number(s) of your emergency contact.  I will also request the address from which you are calling and the number to your local police department including area code in the area in which you are located during the time of our call. 

If a situation occurs where we are talking and get disconnected and you are in crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-784-2433. 

If I have concerns about your safety at any time during a phone session, I will need to break confidentiality and call 911 (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact immediately.  Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.

Consent to Participate in TAC Sessions:

By signing below you agree that you have read and understand all of the above sections of TAC informed consent.  You agree that you also understand the limitations associated with participating in TAC counseling sessions and consent to attend sessions under the terms described in this document.

( Type Full Name )
Health Insurance Portability Accountability Act (HIPAA) Client Rights & Therapist Duties

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.  The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail.  T

he law requires that I obtain your signature acknowledging that I have provided you with this.  If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless I have taken action in reliance on it.  


The law protects the privacy of all communication between a patient and a therapist.  In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary.  Reasons I may have to release your information without authorization:

1.  If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information. ="margin-bottom:>

2.  If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them. ="margin-bottom:>

3.  If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. ="margin-bottom:>

4.  If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

5.  I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:

1.  If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Texas Abuse Hotline.  Once such a report is filed, I may be required to provide additional information. ="margin-bottom:>

2.  If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Texas Abuse Hotline.  Once such a report is filed, I may be required to provide additional information. ="margin-bottom:>

3.  If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.


Use and Disclosure of Protected Health Information:

For Treatment - I use and disclose your health information internally in the course of your treatment.  If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes. ="margin-bottom:>

For Payment - I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.  ="margin-bottom:>

For Operations - I may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights:

Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.   ="margin-bottom:>

Right to Confidentiality - You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  I will agree to such unless a law requires us to share that information. ="margin-bottom:>

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request. 

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. 

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee charge of $1.00 per page.  Please make your request well in advanced and allow 2 weeks to receive the copies.  If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.  

Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.   

Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.  

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, I will discuss with you the details of the accounting process. 

Right to Choose Someone to Act for You - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.   

Right to Choose - You have the right to decide not to receive services with me.  If you wish, I will provide you with names of other qualified professionals.   

Right to Terminate - You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.  I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.  

Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate.  Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you. 

Therapist's Duties:

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.  I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.  If I revise my policies and procedures, I will provide you with a revised notice in office during our session.


If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Texas Department of Health, or the Secretary of the U.S. Department of Health and Human Services.


( Type Full Name )

- I understand that if I fail to cancel a scheduled appointment, D'Arcy & Associates Counseling Services, PLLC cannot use this time for another client and I will be billed for the entire cost of my missed appointment.

- I understand that current out of pocket session rates are $165.00 for the initial session and $135.00 for subsequent 45 minute sessions. These are subject to change with 60 days advance notification.

- If you are using insurance you will pay your copay (unless there is a deductible to meet).  The amount you pay while using insurance varies greatly depending on your plan.  Before your first appointment, your benefits will be verified and the amount you owe will be determined.

- I understand that Mental Health insurance DOES NOT cover the cost for late cancellations or no-show appointments.

- I understand that Mental Health Benefits are determined prior to the initial session and will require a diagnosis for filing a claim. I also understand that final determination of co-pays, co-insurance or deductible occurs once the claim is received and paid, or not. I understand that I am fully and financially responsible for all fees due to D'Arcy & Associates Counseling Services, PLLC.

- I further understand that if insurance denies any claims and makes no payment, I am responsible for payment and authorize D'Arcy & Associates Counseling Services, PLLC to charge my card on file for the balance due. If I disagree with the insurance company's determination of benefits, it is my right and responsibility to contact the Insurance Company directly. I, as the client, am responsible for both my insurance plan and my payment to D'Arcy & Associates Counseling Services, PLLC.

- I acknowledge that the office of D'Arcy & Associates Counseling Services, PLLC provides 48- hour appointment reminders as a courtesy and so I understand and agree to the following: A $85.00 fee will be charged for all appointments cancelled within 24 hours of the appointment if said appointment cannot be rescheduled within the same work week.

- The full appointment fee of $135.00 will be charged for No-Show sessions (sessions missed without notification or cancelled within 4 hours of the scheduled appointment).

- I authorize D'Arcy & Associates Counseling Services, PLLC to keep my signature on file and to charge my credit/debit card account for recurring session charges (including self-pay, co-pay, deductible or co-insurance), fees not paid by insurance, and/or for no-show or late cancellation charges.

- I understand that this form is valid for two (2) years from this date unless I cancel the authorization in writing.

- I agree to not dispute credit card charges ('charge back') for sessions held with D'Arcy & Associates Counseling Services, PLLC, or for late cancellation/no shows.

- Failure to pay within 10 days of a request of payment is considered theft of services under Texas PENAL CODE, Title 7, Offenses Against Property, Chapter 31: Theft, (31.04 b (2)), which states:
(b) For purposes of this section, intent to avoid payment is presumed if:
(2) the actor failed to make payment under a service agreement within 10 days after receiving notice demanding payment;

- I authorize D'Arcy & Associates Counseling Services, PLLC to disclose information (break confidentiality) about my attendance/no-show/late cancellation to my credit card issuer if I dispute any charges associated with a scheduled appointment.

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‌Court Policy

Please be advised that the therapists, therapist interns and staff of D'Arcy & Associates Counseling Services, PLLC do not participate in person, by phone or in writing in any court related matter that the client of D'Arcy & Associates Counseling Services, PLLC may be a party to or become a party to in any way. The therapists and interns of D'Arcy & Associates Counseling Services, PLLC do not write letters regarding their client's treatment to any entity, including court. The therapists and interns of D'Arcy & Associates Counseling Services, PLLC at no time will offer an opinion or recommendation in any court matter, especially as it relates to custody.

If a court order is served and is requesting that a therapist or therapist intern of D'Arcy & Associates Counseling Services, PLLC 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 court and there is no guarantee that the information will be kept confidential. This includes a client's mental health history; current status and inclusive records and may not be in the best interest of the client. The therapist client relationship does not render the therapist as an advocate. The therapist will withhold any opportunity to engage in a dual relationship with the client.

Court Policy & Fee's

Please be advised that should a therapist or intern from D'Arcy & Associates Counseling Services, PLLC be ordered by court to write a letter to the court, the time shall be billed at $350 per hour. 

Please be advised that should a therapist or intern from D'Arcy & Associates Counseling Services, PLLC be court ordered to appear in court, the fee stipulation is as follows:

$2,000 per day plus $200 per hour for travel to and from the court. $350 per hour for preparation

All therapist's and interns of D'Arcy & Associates Counseling Services, PLLC will NOT be ON-CALL at anytime. Should a case be trailed, or continued, the therapist will be paid in full for each day as well as an additional $1,000 per day as it hinders the therapist's or intern's ability to be available to their other clients. 

All court fees must be received by cashier's check 7 days prior to the court date. Should the court, calendar the hearing for another date, the therapist or intern must be re-issued a new subpoena with the new court hearing date.

Should the therapists or interns be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena. 

By signing and dating below, you understand and agree to the above stated court policy and stipulation, including but not limited to the fee structure for all related court matters.

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This document outlines my office policies related to the use of Social Media. Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet.

If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and and make sure that you have a copy of the updated policy.

I do not accept friend requests from current or former clients on any social networking site. I believe that adding clients as friends on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

You may 'like' my FaceBook business page, but I would encourage you to protect your own privacy and confidentiality by not 'liking' it. If you choose to "like" my page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on this page. However, if you find it helpful then that is great!

Note that you should be able to subscribe to the page via RSS without 'liking' it and without creating a visible, public link to my page.

I sometimes publish a blog on my website and I post psychology news on Twitter. I have no expectation that clients will want to follow my blog or Twitter stream. You are welcome to use your own discretion in choosing whether to follow me. Note that I will not follow you back. I mainly follow other health professionals on Twitter and I do not follow current or former clients on blogs or Twitter. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and expire them together, during the therapy hour.

Please do not use messaging on Social Networking sites such as Twitter, FaceBook or LinkedIn to contact me. Also if there were an emergency, I would not be able to respond to you in a timely manner as I do not check these account regularly. The best way to interact with me is by phone or email. If you post on my wall, it may also create the possibility that these exchanges become a part of your legal medial record and will need to be documented and archived in your chart.

You may have a FaceBook page, Instagram account or Twitter account. I do not 'google' my clients or look up information on them for any reason. I believe it is important that I know you as you are in my office. If I come across your information online, I will move on and avoid reading content.

I do have a Yelp page and other directory pages. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating or endorsement from you as my client.

Of course, you have a right to express yourself on any site you wish. If you do post a review, I cannot respond on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. I f we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an impotent part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that I am your therapist or how you feel about the treatment that I provided to you, in any forum of your choosing.

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection.

If you believe that I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can always contact the:

Texas State Board of Examiners of Marriage and Family Therapists
Texas State Board of Examiners of Licensed Professional Counselors
Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369
or call 1-800-942-5540

I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure of confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet Service Provider.

As a client of Delee D'Arcy Therapy, I currently utilize a client portal that allows for HIPAA compliant and secure email. I encourage you to use this form of communication, but again, not as a therapy tool.

Sometimes clients text me to request an appointment time or to let me know that they are running late to our appointment. Just know, text is not always secure. I am fine with brief texts related to your appointment only.

Thank you for taking the time to review my Social Media Policy. If you have any questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them.
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