Outpatient Services Guidelines

Thank you for choosing this psychology office for your mental health needs. Our office policies are shown below. Please read them carefully and sign below. Feel free to discuss any questions or concerns with your psychologist regarding the policies.


Your psychologist will discuss rates with you prior to your first appointment.


Payment in full is due at the time of the visit, unless special arrangements have been made with your therapist in advance.

Cancellation Policy:

Should you be unable to keep an appointment we ask that you give a minimum of 48 hours notice. Since others may need that time, the full session fee will be charged if the 48-hour notice is not given.

Psychological Services:

I order to be successful, psychotherapy requires work both during sessions arid at home.  Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, etc. The benefit is that the therapy often leads to a significant reduction of feelings of distress and resolution of specific problems.

It can take from one to three sessions for an initial evaluation. After that time your psychologist will offer initial clinical impressions and a potential treatment plan, should you decide to
continue. Please consider this information along with your own assessment of your issues and whether you feel comfortable working with your psychologist. Meetings are usually scheduled once per week.

Professional Fees:

The fees apply to appointments. In addition to weekly appointments, this amount is charged on a prorated basis for other services you may require such as report writing, telephone conversations which last longer than 5 minutes, attendance at meetings or consultations with other professionals which you have authorized, preparation of reports or treatment summaries, or the time required to perform any other service which you may request.

Although we do not accept insurance, we will provide you with a receipt that you can submit to your insurer to facilitate receiving benefits to which you are entitled. However, you and not your insurance company are responsible for full payment of the agreed upon fee. Therefore, it is very important that you find out exactly what mental health services your insurance policy covers.

Contacting Your Psychologist:

We request that you leave a message in the office for routine questions or itt::ms, such as appointment changes. I will make every effort to return your call on the same day that you make it, with the exception of weekends and holidays. You may call the office number in an emergency situation, but, as your psychologist may be with another patient or be unavailable at that time, it is strongly recommended that in any emergency in which you are not confident of being able to keep yourself safe, you go to the nearest hospital emergency room.

Contacting the Patient:

By providing us with your various telephone numbers, you are giving us permission to call you at those numbers. Please also provide us with your email address so that we may use that to provide you with information from our website and other psychological information. However, we do not use email or text messages to make or reschedule appointments, or to· communicate about clinical issues since text and email are not secure methods of communication.

Mandatory Reporting:

If we believe that a child, elderly individual, or disabled person is being abused, we are required to file a report with the appropriate agency. If we believe that a client is threatening serious bodily harm to another, we are required to take protective action which may include notifying the potential victim, the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, we are required to seek protection for the client, which may include contacting family members or others who can help provide protection, a local hospital crisis center, or contacting the police.


All sessions are confidential and the information you provide is protected under the Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information, a copy of which can be found in the waiting room. Your signature below indicates that you are aware of the privacy policies. In the interest of providing the highest quality treatment, Dr. Block may participate in meetings with other therapists in which cases are discussed, but no identifying information about any individual client is revealed. We may also find it helpful to consult about a specific case with other professionals, and· again, no identifying information is revealed.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

Outpatient Services

Acceptance of Guidelines

Sign Here