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Office Policies and Client Consent
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Today's Date
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Full Name
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Phone Number
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Email
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Emergency Contact
Relationship to You
Contact’s Phone Number
Consent
In case of an emergency, I give Jonathan Stein permission to contact the person listed above:
48-Hour Cancellation Policy:
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I agree to the cancellation policy.
If you need to cancel your session, please contact Jonathan at least 48 hours in advance to avoid being billed for the session. If you cancel your session with less than 48 hours' notice or miss your session without any notice, you are responsible for the full payment of the missed session as Jonathan has set aside that time for you.* However, he will do his best to accommodate you and reschedule your session within the same week to avoid being billed for the missed session, though this cannot be guaranteed.
Cancellations can be made using text or VM. Please do not use email as I don’t check that as often.
* While I understand that unforeseen circumstances can arise, I ask that clients be mindful of the impact that cancellations have on my availability and schedule. In cases of severe illness or emergency, I will consider rescheduling or waiving the cancellation fee. However, please note that repeated use of this policy may impact my ability to be flexible in the future.
Late Policy:
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I agree to the late policy.
Please inform Jonathan if you are going to be late for a session. If you have not arrived and he has not heard from you by approximately 5 minutes after the start of the session, he will contact you by phone or text. If you do not respond, he will wait until 15 minutes past the start of the session before considering it a missed session and you will be billed according to the Cancellation Policy. See above.
Frequently Missed Sessions:
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I understand that I am responsible for my participation.
It’s common to occasionally skip appointments for various reasons. Nonetheless, when you decide to engage in ongoing sessions with me, you’re dedicating yourself to your overall wellness and agreeing to attend regular meetings with me at predetermined intervals. You are responsible for your participation and should be aware of the Cancellation Policy and Late Policy stated above. If you miss numerous sessions, I will likely ask why. From time to time, especially if such occasions arise with frequency, I may initiate a conversation to determine if you feel that our work together is progressing to your expectations, or if your commitment to the work has changed. In rare instances, when a client misses many sessions, I may suggest that we end our meetings and that the client should consider looking for a new practitioner to work with.
Once again, I value your time and hope that you value mine! Missed appointments or appointments canceled on short notice do affect me and also prevent me from being able to serve others in need.
How do I end treatment?
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I understand
It’s common to occasionally skip appointments for various reasons. Nonetheless, when you decide to engage in ongoing sessions with me, you’re dedicating yourself to your overall wellness and agreeing to attend regular meetings with me at predetermined intervals. You are responsible for your participation and should be aware of the Cancellation Policy and Late Policy stated above. If you miss numerous sessions, I will likely ask why. From time to time, especially if such occasions arise with frequency, I may initiate a conversation to determine if you feel that our work together is progressing to your expectations, or if your commitment to the work has changed. In rare instances, when a client misses many sessions, I may suggest that we end our meetings and that the client should consider looking for a new practitioner to work with.
Ending treatment is best when done in a planned, mutually agreed-upon way. Stopping treatment without such an arrangement can undermine or “undo” progress that you’ve made in your sessions. You are welcome to return for sessions at any time in the future provided space in my practice is available.
Payment:
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I understand that: Jonathan Stein is not on any insurance panels. All sessions are conducted on a private pay basis. Clients are expected to pay either before or immediately after each session. Payments are accepted through PayPal, Venmo, and credit cards.
Note
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I understand that Jonathan is not available to provide diagnosis or procedure codes that out-of-network insurance may require for you to be reimbursed for sessions, nor is he available to submit to clients, clients’ guardians, or insurance companies any kind of Mental Health Claim Form. This is the sole responsibility of the client or the client’s guardian.
Video Platform Options:
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I acknowledge that Jonathan offers counseling sessions through different video platforms, including FaceTime, Zoom, WhatsApp, Doxy, and Psychology Today. Of these options, Doxy and Psychology Today offer private, encrypted platforms that are HIPAA-certified. I understand that I have the right to choose the platform that best suits my needs. I agree that I have been informed of my options and Jonathan is released from all liability based on my choice of video platform.
Confidentiality Agreement:
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All information you share in sessions with Jonathan is confidential. The only time that Jonathan is required to disclose your information is if your mental/emotional state has placed you or someone else in physical danger. If such an instance should arise, and whenever possible, he will inform you prior to disclosing any personal information about you to a third party.
Professional Qualifications and Scope of Practice:
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I understand that Jonathan has completed Master’s level training and extensive clinical application of Transpersonal Psychotherapy, Drama Therapy, and Holistic Counseling, as well as numerous other conventional and complimentary mental health approaches. He uses the professional title, “Holistic Mental Health Practitioner”, and provides “holistic mental health sessions” to describe his services. Jonathan is not a state-licensed practitioner and does not diagnose any mental illness or disorders, or prescribe medications.
Disclosure of Diagnosed Disorders and Termination Protocol
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I acknowledge and agree that: if I have received a diagnosis for any disorder, it is imperative to discuss this directly with Jonathan before commencing our work together. If it becomes apparent, either during or after the commencement of our work together, that I have a diagnosed disorder or if such information is disclosed subsequently, I understand and agree to promptly inform Jonathan. As a Holistic Mental Health Practitioner, Jonathan will not treat mental health disorders. I understand that in such cases, our professional collaboration may need to be reconsidered, and termination of our work together might be necessary. In the event of termination, Jonathan will make every effort to provide appropriate referrals to qualified practitioners to ensure ongoing support for my well-being. Open communication about any evolving circumstances is essential for the best possible support and guidance throughout our professional relationship.
(If applicable) Consent to Session with a Minor:
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I authorize Jonathan Stein to facilitate a session with my child or dependent, and I understand that all office policies listed above apply.
Note: If you have questions or concerns about anything in this intake or consent form, please reach out to Jonathan.
By signing below, I state that I have read, understand, and agree with the terms defined on this form.
Signature
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Type your name to serve as your electronic signature.
Date
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