Resources & Forms

If you wish to download this information in PDF format, please click here.

Welcome to my practice. This document outlines important information about the services I provide and our professional agreement. Please review it carefully and bring any questions to our next session.

Psychotherapy varies based on your goals, the challenges you’re facing, and the therapeutic relationship. It’s not like a medical appointment—it requires active participation both during and between sessions. Therapy may involve discussing difficult topics, which can bring up uncomfortable emotions. However, many people find it leads to meaningful growth, better relationships, and relief from distress. 

Our first few sessions will focus on understanding your needs and determining whether therapy with me is a good fit. I’ll share my impressions and suggest a treatment approach. If I believe another provider may be better suited, I will offer appropriate referrals.

Because therapy involves a significant investment of time and energy, it’s important that you feel comfortable with your provider. If at any time you have questions or concerns, I encourage open conversation and, if needed, can help you connect with another professional for a second opinion.

Appointments & Cancellations

Initial sessions are typically used for evaluation and may take 2–4 appointments. This time helps us determine whether we are a good fit for working together. If we agree to move forward, sessions are generally scheduled once per week for 45-50 minutes, though we may adjust frequency as needed.

Once an appointment is scheduled, you are responsible for attending or giving at least 24 hours advance notice if you need to cancel. If you cancel late or do not attend, you may be charged for the missed session unless the absence was due to circumstances beyond your control.

Professional Fees

My standard rate is $130 for individual counseling, $70 for skills training/coaching and $160 for combined therapy. Extended sessions or additional professional services—such as report writing, phone consultations lasting over 15 minutes, treatment summaries, or collaboration with other providers—are billed at the same hourly rate ($130), prorated for shorter durations. 

Evaluation rates vary according to complexity of the referral concern. To secure an evaluation appointment and initiate formal testing, full payment is required prior to the first testing session. A Good Faith Estimate outlining the total evaluation cost will be provided in advance. Evaluation appointments are not guaranteed until payment is received in full. 

If I am involved in legal matters at your request or due to a court order, additional fees will apply. I charge $165 per hour for legal-related services and an additional fee per page for any records requested. 

Billing & Payment Policy

Payment is due at the time of service unless we have agreed otherwise. Payment for evaluations is required in full prior to the initiation of any formal testing or assessment procedures. We accept payment in cash, check or Venmo @CloserHorizons. Payment plans or adjustments may be available in cases of financial hardship.

If your account remains unpaid for over 60 days without a payment arrangement, I may refer your balance to a collection agency or pursue small claims court. In such cases, only the minimum necessary information (e.g., your name, dates of service, and amount owed) will be shared. 

Insurance Reimbursement

Closer Horizons is a private pay practice and does not accept insurance. You are responsible for full payment of all fees. Upon request, I can provide a superbill that you may submit to your insurance provider for potential out-of-network reimbursement. Please note that reimbursement is not guaranteed and depends on your plan’s policies. 

Contacting Me

I am not always immediately available by phone (502-281-7432) or email (hello@closerhorizons.com), as I may be in session or away from the office. My typical hours are 9AM to 3PM, Monday through Friday. If you leave a message, I will make every effort to return your call or email within 1-2 business days, except on weekends and holidays. 

If your matter is urgent and you are unable to wait for a response, please contact your primary care physician, dial 911, or go to the nearest emergency room. If I plan to be unavailable for an extended time, I will inform you in advance and provide the name of a colleague to contact if needed.

Confidentiality

In general, the information you share with me is private and protected by law. I will not release any details about our work without your written permission, except in a few specific situations required by law. 

Exceptions to Confidentiality

Legal Proceedings: In most cases, you have the right to keep your treatment confidential. However, a judge may order me to share information if the situation warrants it.

Safety Concerns: I may be required to break confidentiality if I believe:

• A child, elderly person, or individual with a disability is being abused.

• You are at risk of harming yourself or someone else.

• A protective action (such as notifying authorities or arranging hospitalization) is necessary for safety.

•  Whenever possible, I will discuss these concerns with you before taking action.

Professional Consultation

At times, I may consult with other licensed professionals to provide the best care. These consultations are confidential, and I take care not to reveal your identity. Consultants are also bound to uphold your privacy.

Consent and Agreements

This summary includes important information about confidentiality and its exceptions. If you have questions or concerns, please bring them to our next session so we can discuss them together. I’m happy to offer clarification, though in some cases, legal consultation may be appropriate, as confidentiality laws can be complex.

By filling out the form below, you acknowledge that you have read and understood this informed consent and agree to its terms as part of our professional relationship.

ADDENDUM FOR CHILD/ADOLESCENT CLIENT

Parent Authorization for Minor’s Mental Health Treatment

To consent to treatment for your child, you must have legal custody. If you are divorced or separated, please inform me immediately and provide a copy of the most recent custody agreement. In most cases, I will notify the other parent that their child is receiving therapy, unless there are exceptional legal or safety concerns.

Parent Involvement & Disagreements

Therapy for minors can sometimes bring up differing opinions between parents or between parents and the therapist. I will make every effort to listen, understand your perspectives, and collaborate respectfully. If one parent decides to end therapy, I will honor that decision unless there are extraordinary circumstances. In those cases, I may request a few closing sessions with your child.

Communication with Parents

I may meet with parents/guardians during the course of therapy, but please note: my client is your child—not the parents or other family members. Notes from these meetings may be included in your child’s treatment record and will be accessible to those with legal access.

Required Disclosures

There are some situations where I am legally required to break confidentiality, even without your or your child’s consent. These include:

When a child plans to seriously harm themselves or others

When there is a risk of serious harm, even if unintentional

When abuse or neglect of a child is suspected or reported

When ordered by a court

Privacy & Confidentiality for Minors

Building trust is key to therapy, especially with teens. To support your child’s growth and autonomy, I provide parents general updates but do not share specific details without the child’s consent—unless there is a concern for serious and immediate harm.

Examples:

• I will not share: A child tries alcohol at a party or talks about dating or sexual activity that is safe and consensual.

• I will share: Risky behavior like drinking and driving, repeated unsafe sex, or suspected addiction.

• If I believe it’s important for you to know something, I will encourage your child to share it and support them in how to do so. I may also share general insights to help you support your child without disclosing private details.
  

Access to Records

By signing this consent, you agree to respect your child’s privacy and not request access to their written therapy records, even if state law might otherwise permit it. This supports a safe and trusting therapeutic space.

Parent/Guardian Agreement Regarding Custody Matters

When families are navigating separation, divorce, or custody issues, therapy can be an important support for children. My role is solely to provide therapeutic care for your child—not to evaluate or comment on custody or parental fitness.

By signing this agreement, you agree that neither parent will request my records, ask me to testify in court, or seek my opinion about custody, visitation, or parental fitness in any legal proceedings. I will not provide letters, evaluations, or affidavits for use in custody litigation.

Please note that while this agreement reflects our mutual understanding, it does not prevent a judge from legally compelling my testimony. If required to appear or provide documents, I am ethically bound not to offer custody recommendations. In such cases, I may share general information with court-appointed professionals (e.g., a guardian ad litem or custody evaluator) only if a valid release or court order is provided.

If I am required to participate in legal matters, the responsible party agrees to pay for my time at a rate of $165 per hour. This includes preparation, travel, communication with attorneys, court attendance, and related tasks.

Consent and Agreements (Child/Adolescent Patient)

By filling out the form below, you confirm that you understand and agree to the terms described above. You are welcome to ask questions at any time during the course of therapy.

If you wish to download this information in PDF format, please click here.

This document explains how therapy services may be provided remotely using video or phone (telepsychology). Please read it carefully. Signing this form means you understand and agree to receive services in this format. If you have any questions, feel free to ask at any time. 

What is Telepsychology?

Telepsychology allows us to meet for therapy without being in the same physical space. You can attend sessions from a private location that works best for you. This flexibility can make it easier to access support, but there are also some differences and risks compared to in-person therapy. 

Potential Benefits

• More convenient access to care

• No need to travel to appointments

• Continuity of services during illness, weather issues, or schedule changes

Potential Risks

1. Privacy and Confidentiality

• Sessions happen outside of a private office, so there is a risk of others overhearing if you’re not in a private location.

• I take steps to protect your privacy on my end, but you are responsible for finding a quiet, private place and using a secure internet connection.

• Avoid public Wi-Fi and make sure others cannot hear or interrupt our session.

2. Technology Challenges

• Internet or phone connections may occasionally drop or freeze.

• Although we use secure, HIPAA-compliant systems, no technology is completely risk-free.

• There is a small possibility of unauthorized access to our session or your information.

3. Crisis Limitations

• Telepsychology may not be appropriate if you’re in a crisis or need more intensive support.

• We’ll work together to create a safety plan in case an emergency arises during a session.

• We’ll regularly check in to ensure this format continues to meet your needs. 

4. Personal Preference

• Research shows telepsychology is generally as effective as in-person therapy.

• Still, some clients and clinicians feel that being physically together allows for better connection and understanding of body language.

• We’ll continue to discuss whether this format feels right for you.

Electronic Communication & Technology Use

To participate in telepsychology, you’ll need access to certain technology—like a smartphone, tablet, or computer—and a strong internet or mobile data connection. You are responsible for any costs related to your device, internet service, or software needed for our sessions.

Communication Outside of Sessions

• Email and Texting: I use email or text only for basic administrative matters like scheduling, billing, or confirming appointments—and only with your permission.

• Please do not use email or text to share clinical or personal concerns. These methods are not fully secure, and I cannot guarantee confidentiality.

• I don’t check email or texts constantly, so please do not use them in an emergency.

If You Need Urgent Support

• If something urgent comes up, you may try to reach me by phone. I’ll do my best to return your call within 24 hours, Monday through Friday.

• If you feel unsafe or need immediate help, please call 911, go to the nearest emergency room, or contact your primary care provider.

• If I plan to be away for an extended time, I’ll provide you with the name of another trusted clinician you can reach if needed.

Confidentiality in Telepsychology

I am committed to protecting your privacy and will take reasonable steps—such as using secure platforms, updated encryption, and firewall protection—to keep our telepsychology sessions confidential. However, because we are using technology, I cannot guarantee complete privacy. There is always a small risk that electronic communications may be intercepted, compromised, or accessed by others.

What You Can Do

To help keep our sessions secure, please:

• Use a private, quiet space for sessions

• Protect your devices with passwords

Connect only through secure, password-protected internet networks

Confidentiality Still Applies

The same rules about confidentiality and its limits that apply to in-person therapy also apply to telepsychology. If you have questions about when I may be required to break confidentiality (e.g., in cases of danger to self or others), please feel free to ask.

Location

I am a PSYPACT-authorized provider and hold an active Authority to Practice Interjurisdictional Telepsychology (APIT) through the Association of State and Provincial Psychology Boards (ASPPB). This credential allows me to offer telepsychology services to clients located in any of the 42+ states participating in PSYPACT.

If you plan to travel or relocate outside of a PSYPACT state, please let me know in advance so we can plan accordingly and resume therapy upon your return.

Appropriateness of Telepsychology

Telepsychology may not be the best fit for every situation. At times, we may schedule an in-person session to check in. If I determine that telepsychology is no longer appropriate for your needs, we’ll discuss other options, such as transitioning to in-person services or a referral to a local provider.

Emergencies & Technology Interruptions

Crisis situations are harder to assess remotely. To prepare, we’ll create a safety plan before beginning telepsychology services. You’ll also provide the name and contact information of someone local who can help in an emergency. I’ll ask you to sign a release so I may contact this person if needed.

If we are disconnected during a session and you’re in crisis, do not call me back. Instead, call 911 or go to the nearest emergency room. Once you’re safe, you can follow up with me.

If a session is interrupted and cannot be resumed, you’ll only be billed for the portion we completed.

Fees

My fees for telepsychology are the same as for in-person sessions. Some insurance plans may not cover telehealth services, so please check with your insurer in advance if you plan to request reimbursement.

Records & Recordings

Telepsychology sessions are not recorded unless we both agree in writing. I document remote sessions the same way I document in-person visits, following the same privacy and recordkeeping standards.                 

Informed Consent

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Filling out the form below indicates agreement with its terms and conditions. 

If you wish to download this information in PDF format, please click here.

Introduction

This Notice explains how we use and disclose your protected health information (“PHI”) and your rights under HIPAA. PHI includes any information that can be used to identify you and relates to your health, healthcare services, or payment.

How We May Use & Disclose Your PHI Without Your Authorization

• Purpose: Treatment

• Description: Coordinating your care across providers

• Example: Sharing test results

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• Purpose: Payment

• Description: Billing, insurance claims, eligibility reviews

• Example: Submitting claims

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• Purpose: Healthcare Operations

• Description: Quality review, staff training, customer service

• Example: Auditing documentation

We may also use your PHI:

To send appointment reminders or information on treatment options.

With individuals involved in your care (e.g., family members).

To comply with public health, legal, and law enforcement requirements (e.g., court orders, reporting abuse, medical examiner requests).

Uses & Disclosures Requiring Your Written Authorization

Except for the purposes listed above, we will only use or share your PHI with your explicit written permission. You may revoke authorization anytime—except where action has already been taken in reliance on it.

Your Rights Under HIPAA

You have the right to:

1. Request restrictions on PHI use/disclosure (we are not required to agree).

2. Receive confidential communications at alternative locations or via different methods.

3. Access, inspect, and copy your PHI (e.g., medical records) within 30 days of your request.

4. Request amendments to your PHI if you believe it is inaccurate or incomplete.

5. Obtain an accounting of disclosures not related to treatment, payment, or healthcare operations.

6. Receive a paper copy of this Notice upon request.

7. Be notified of any breach involving your unsecured PHI.

Changes to This Notice

We are required to follow this Notice while in effect. We may update it to reflect changes in law or privacy practices. Updated versions will be posted prominently in our office and on our website. Patients may receive an updated copy upon request.

Acknowledgement & Consent

By filling out the form below, I confirm that:

• I have received and reviewed the Notice of Privacy Practices.

• I understand that my PHI may be used or disclosed for treatment, payment, and healthcare operations.

• I understand that other uses require my prior written authorization.

• I am aware of my rights regarding my PHI as outlined above.

Thank you for trusting Closer Horizons with your care.