Consent For Treatment

Consent for treatment from Gerald Winter MS

“I understand that the service provided are not intended for crisis situations and urgent needs. In a crisis, I agree to call 911 or local emergency services, or visit the nearest emergency room. Information shared with your counselor is considered confidential except in the following circumstances: If I present as a danger to myself or others, mandated reporting of abuse of children or elders, or if I sign a release of information.
I would also like to let you know that scheduled sessions should start on time, if for some reason they do not, I will wait 15 minutes, if you are not there by then, I will work on something else, and you may have to reschedule your appointment with me. Any missed session without giving 24-hour notice can be made up for an additional fee of 55.00. This contract is for once-a-week sessions.

Payment for services: examples only,

Option #1: 55.00 per session payable at the end of each month after you have had your sessions,
Option #2: 200.00 per month for four sessions, paid on the first of every month before your first session each month. Five dollars a session discount for paying in advance,
Option #3: 55.00 per session to be billed and paid after each session. A session is considered up to 45 minutes in length.
Accepted payments will be billed to you on a month-by-month basis at the end of each month through your email address, or as stated above, unless you would prefer a different way. Acceptable forms of payment methods include PayPal to ____ and or Zelle to ____ or my phone number above. We also now accept most major credit cards and personal checks. There is a 3.1 percent credit card convenience fee that you agree to pay by using your credit card.
Also, any required paperwork will be billed at 55.00 per hour with a minimum of one hour.
Also, if you cancel a session without giving 24 hours’ notice in advance or do not show, you will be charged for your session at the same amount. All communication will be completed through this same email address and or through text via cell-phone.
All services will be rendered in an electronic format through Zoom, if you do not have Zoom you will have to download it to your computer. A link to your scheduled meeting will be sent in advance once times are agreed upon. Or if you prefer to do phone calls you can call me on my phone, listed above. If using your phone, it will be your responsibility to contact me for any scheduled sessions.
If you would like to reserve the same time every week, just let me know and that can be arranged, any changes to your reserved time, would have to be discussed in advance. For example, if you would like every Friday at 10 am EST, that time slot will be set aside only for you with the exception if it falls on a holiday. I may or may not be able to reserve a certain time for you for your first week of service, depending on how much notice you give me in advance of your preferred time slot.
By signing and dating the above you understand and agree with the above conditions. All signatures are considered electronic signatures and will remain valid until either the counselor or the client wish to terminate services.
Printed Name and signature and date signed, if typed your typed name is considered your electronic signature.

Privacy Policy

All client information is held in strict confidence and will not be shared with anyone except under the following conditions: threatening to harm self or others, any reported child abuse and or if you sign a release of information.