All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Compassion Centered Therapy for Women LLC that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Compassion Centered Therapy for Women LLC. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Compassion Centered Therapy for Women LLC will use clinical judgment when revealing such information. Compassion Centered Therapy for Women LLC will not release records to any outside party unless authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

If there is an emergency during therapy, or in the future after termination, where Compassion Centered Therapy for Women LLC becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, we will do whatever we can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the emergency contact person whose name you have provided on the biographical sheet.

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Compassion Centered Therapy for Women LLC, only the minimum necessary information will be communicated to the carrier. Compassion Centered Therapy for Women LLC has no control over, or knowl edge of, what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients’ records are generally confidential and private in nature. Compassion Centered Therapy for Women LLC reserves the right to refuse disclosure of such clinical documentation. However, you, as the client, have the right to review your own psychotherapy records anytime. CONSULTATION: Compassion Centered Therapy for Women LLC consults regularly with other professionals regarding clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

It is very important to be aware that computers and unencrypted email and texts communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails and texts are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails and texts that go through them. While data on Compassion Centered Therapy for Women LLC‘s laptops are encrypted, emails and texts are not. It is always a possibility that texts and email can be sent erroneously to the wrong address and computers. Compassion Centered Therapy for Women LLC’s laptops are equipped with a rewall, a virus protection and a password, and the practice backs up all confidential information from the computer on a regular basis onto an encrypted hard- drive. Please notify Compassion Centered Therapy for Women LLC if you decide to avoid or limit, in any way, the use of email, texts, cell phone calls, or phone messages. If you communicate confidential or private information via unencrypted email, texts or via phone messages, we will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters. Please do not use texts, email, voice mail, or faxes for emergencies.

Both the law and the standards of Compassion Centered Therapy for Women LLC require that we keep treatment records for at least 7 years. Please note that clinically relevant information from emails and texts are part of the clinical records. Unless otherwise agreed to be necessary, Compassion Centered Therapy for Women LLC retains clinical records only as long as is mandated by Arizona and California State law. If you have concerns regarding the treatment records, please discuss them with Compassion Centered Therapy for Women LLC. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Compassion Centered Therapy for Women LLC assesses that releasing such information might be harmful in any way. In such a case, Compassion Centered Therapy for Women LLC will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Compassion Centered Therapy for Women LLC will release information to any agency/person you specify unless Compassion Centered Therapy for Women LLC assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Compassion Centered Therapy for Women LLC will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

Both the law and the standards of Compassion Centered Therapy for Women LLC require that we keep treatment records for at least 7 years. Please note that clinically relevant information from emails and texts are part of the clinical records. Unless otherwise agreed to be necessary, Compassion Centered Therapy for Women LLC retains clinical records only as long as is mandated by Arizona and California State law. If you have concerns regarding the treatment records, please discuss them with Compassion Centered Therapy for Women LLC. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Compassion Centered Therapy for Women LLC assesses that releasing such information might be harmful in any way. In such a case, Compassion Centered Therapy for Women LLC will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Compassion Centered Therapy for Women LLC will release information to any agency/person you specify unless Compassion Centered Therapy for Women LLC assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Compassion Centered Therapy for Women LLC will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved 2 2/2024in the treatment.

Clients are expected to pay the standard fee of $180 per 55 minutes at the end of each session, unless other arrangements have been made. Because we want to ensure that individuals have access to quality therapy services regardless of coverage, a sliding scale rate is offered for cash pay clients at $150 per 55 minute session. Telephone conversations, writing and reading of reports, longer sessions, will be charged at the same rate, unless indicated and agreed upon otherwise. If any problems arise during the course of therapy regarding your ability to make time please notify Compassion Centered Therapy payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of privacy and payment risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Compassion Centered Therapy for Women LLC can use legal or other means (courts, collection agencies, etc.) to obtain payment.

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully; I understand them and agree to comply with them.

Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, in order to change your thoughts, feelings, and/or behavior. Compassion Centered Therapy for Women LLC will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Compassion Centered Therapy for Women LLC may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy Compassion Centered Therapy for Women LLC is likely to draw on various psychological approaches according, in part, to the problem that is being treated and assessment of what will best benefit you. These 3 2/2024approaches include, but are not limited to: art therapy, play therapy, sand play therapy, Cognitive Behavior Therapy (CBT), hypnosis, Mindfulness-Based Cognitive Therapy (MBCT), personality measure psycho-education, Social Thinking (r) education, non-clinical mindfulness practice, and psycho-education training, Eye Movement Desensitization and Reprocessing (EMDR), Spiritual exploration, Transactional Analysis, Gestalt Therapy, Solution Focused Therapy, trauma informed yoga, hypnosis/guided imagery, existential, developmental, humanistic or other psycho-educational training. Compassion Centered Therapy for Women LLC provides neither custody evaluation recommendation nor medication or prescription recommendation, nor legal advice, as these activities do not fall within our scope of practice. Compassion Centered Therapy for Women does not diagnose other people, determine what is a cult, or write letters of recommendation or support for custody or court proceedings.

Within a reasonable period of time after the initiation of treatment, Compassion Centered Therapy for Women LLC will discuss with you our working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, the possible risks, Compassion Centered Therapy for Women LLC’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

As set forth above, after the first couple of meetings, Compassion Centered Therapy for Women LLC will assess if we can be of benefit to you. Compassion Centered Therapy for Women LLC does not work with clients who, in our opinion, we cannot assist therapeutically. In such a case, if appropriate, we will give you referrals that you can contact. If at any point during psychotherapeutic services, Compassion Centered Therapy for Women LLC either assesses that we are not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, we will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, we would give you several referrals that may be of help to you. If you request it and authorize it in writing, and sign a Release of Information. Compassion Centered Therapy for Women LLC will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, Compassion Centered Therapy for Women LLC will give you several referrals that you may want to contact, and if we have your written consent, we will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Compassion Centered Therapy for Women LLC will provide you with names of other qualified professionals whose services you might prefer.

Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Compassion Centered Therapy for Women LLC's objectivity, clinical judgment or can be exploitative in nature. Compassion Centered Therapy for Women LLC will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual and rehabilitation communities, etc., multiple relationships are either unavoidable or expected. Compassion Centered Therapy for Women LLC will never acknowledge working with anyone without his/her written permission. Many clients have chosen Compassion Centered Therapy for Women LLC as their therapist because they knew him/her before they entered therapy with him/her, and/or are personally aware of his/her 4 2/2024professional work and achievements. Nevertheless, Compassion Centered Therapy for Women LLC will discuss with you the often-existing complexities, potential benefits and dificulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise Compassion Centered Therapy for Women LLC if the dual or multiple relationship becomes uncomfortable for you in any way. Compassion Centered Therapy for Women LLC will always listen carefully and respond to your feedback and will discontinue the dual relationship if we end it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

We do not accept friend requests from current or former clients on social networking sites. We believe that adding clients as friends on these sites and/or communicating via such sites can compromise privacy and confidentiality. For this same reason, we request that clients not communicate with us via any interactive or social networking web sites.

Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by Compassion Centered Therapy for Women LLC.

Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 72 hours (3 days) notice via email is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions (not just co-pay) missed without 72 hour notification by email. For these purposes, we will make a copy (or notate the relevant information) of your current credit card and place this securely in your file. Please note, that this information will remain locked and confidential. However, in the occurrence of missing a therapy session (and without prior notification of the absence), we charge your credit card for the previously addressed session fees and time. Please cancel appointments via email not text.

In group therapy, it is of utmost importance that all members maintain confidentiality and disclose neither the content of sessions nor the identity of fellow group members. It is highly recommended that any meaningful exchange outside the group also be discussed in the group. In group therapy, the other members of the group are not therapists; therefore, they are not regulated by the same ethics and laws that bind the therapists. The limits of confidentiality and the reporting laws have been outlined earlier in this document. While the expectation is that all group members will maintain confidentiality, you cannot be certain that they will always keep what you say in the group confidential. You are ultimately responsible for what you say and what you think, feel, or do with the feedback you receive in the group. Hence, it is important to approach outside relationships with other group members with caution and consent.

(Licensed Clinical Social Work license) in both California and Arizona. Jeanine works and lives in Arizona. Therapy work in California will be via teletherapy. Jeanine has a bachelor's degree and master's degree in clinical social work. Jeanine earned a non-traditional doctorate in life coaching in 2006 completing a dissertation on existential suffering. In her current capacity as a therapist, Jeanine works using her clinical social work license and Jeanine does not use the "doctorate" designation in this current capacity. In the past, when not holding a clinical social work license, Jeanine used the doctor designation and was clear online, on radio shows, in published works, earned certificates and audio recordings that she was a doctor of life coaching. Jeanine no longer works as a life coach. Jeanine is clear with clients that any past publications or public works using a doctor, refers to the life coaching doctorate. Jeanine is not a Ph.D. in psychology or social work at this time.

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully; I understand them and agree to comply with them.

Compassion Centered Therapy for Women LLC is in network with several insurances. For all other insurance policies please refer to the billing agreement for information on requesting out of network reimbursement. Please call your insurance company to make sure your provider is in the network. My NPI number is 1134681539.

Your health insurance carrier will be billed the standard fee of $180.00 per 55 minutes at the end of each session. Please note it is the client’s responsibility to be aware of behavioral health coverages under your specific insurance plan. This includes, but is not limited to, a baseline deductible that may need to be met prior to your insurance carrier covering costs for your behavioral health services, any co-pays due by you at the end of each therapy session, and any other relevant information needed to assist Compassion Centered Therapy for Women LLC with communicating with your insurance carrier.

Clients should be aware that not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is rejected or unpaid by your insurance carrier for any reason, you will be held accountable and responsible for the full and/or remaining balance of therapeutic services rendered by Compassion Centered Therapy for Women LLC. Please call your insurance carries to make sure you are in the network.

It is the client’s responsibility to be away of their insurance coverage and pay for any associated fees that occur due to insurance nonpayment, deductibles, copays or other incurred fees. Clients are responsible for the full session cost in instances of claim rejections for any reason. Clients must inform clinician of any insurance changes immediately.

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Compassion Centered Therapy for Women LLC, only the minimum necessary information will be electronically communicated to the carrier. Compassion Centered Therapy for Women LLC has no control over, or knowledge of, what insurance companies do with the information submitted or who has access to this information.

You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or employment. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies.

I, (client/guardian) agree to pay for psychotherapy services and other clinical services for (client) according to the fee agreement between the therapist and the client. I understand the following terms apply to this agreement:

It is important to be aware that email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Texts, in particular are vulnerable to such unauthorized access. It is important that you be aware that emails are part of the medical records. Un-encrypted emails are even more vulnerable to unauthorized access. As a result, Compassion Centered Therapy for Women LLC requires client consent before electronic communication can occur for clients who are currently engaged or have been engaged in the past with psychotherapy services through Compassion Centered Therapy for Women LLC. Please do not use email for emergencies. Phone messages and emails are checked frequently but may not be checked for long periods of time. Do not contact Compassion Centered Therapy for Women for emergencies. To cancel or schedule appointments, please utilize phone calls or email rather than texts.

I understand that I have the right to revoke this confidentiality release agreement at any time. This consent is in effect 2 years from the date of the last session, unless it is revoked in writing earlier or renewed. This consent is also subject to all conditions outlined in the Informed Consent form (in the Welcome Packet).

Please fill out this biographical background form as completely as possible. It will help us in our work together. Information is confidential as outlined in the informed consent form and the HIPAA Notice of Privacy Practices. Please print or write clearly and either bring it with you to the first session OR email it prior to your session: info@CompassionCenteredTherapyforWomen.com

I hereby appoint Jeanine Austin Stotts, MSW, LCSW as custodian of my mental health records after my death. This Directive refers to confidential records created while under his/her care. I authorize Jeanine Austin Stotts, LCSW to refuse to disclose any Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information (45 CFR Parts 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or other confidential medical records, as de ne in AZ and CA state law, whether now existing or hereafter created, related to my mental health.

Such Protected Health Information or mental health records shall not be provided to my spouse, my lineal ancestors or descendants, my personal representative, my personal representative’s respective attorneys, any court, attorney, licensing board, coroner’s office or medical examiner personnel, other governmental, state or other agency, or any other persons or entities.

If I have authorized someone to receive my Protected Health Information under the Standards for Privacy of Individually Identifiable Health Care Information under HIPAA, or other state’s laws, such authorization shall not apply to Jeanine Austin Stotts, MSW, LCSW.

This e-mail, and any attachments, are intended only for use by the addressee(s) and may contain privileged, private or confidential information. Any distribution, reading, copying, or use of this communication and any attachments, by anyone other than the addressee, is strictly prohibited and may be unlawful. If you have received this e-mail in error, please immediately notify me by e-mail (by replying to this message) or telephone 480.510.0600 and permanently destroy or delete the original email, any copy or print out of this e-mail, and any attachments.

It is important to be aware that e-mail communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Un-encrypted e-mails, such as this, are even more vulnerable to unauthorized access. Please notify Jeanine Austin Stotts, LCSW Licensed Clinical Social Worker if you decide to avoid or limit in any way the use of e-mail. Phone (call and text) and email messages are checked irregularly except when therapist is on vacation.

“Telehealth” or “teletherapy” is designed to be the mode of delivering health care services (psychotherapy) via information and communication technologies (e.g. phone or internet) to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site (where you are currently residing) and the health care provider is at a distant site (where the therapist is residing).

• The connection may not be stable. Video can freeze, audio can be dropped, the connection may go black, and if you are in a state of crisis (considering self-harm or suicide), losing the connection would be very bad. A wired connection to your mobile device is ideal, but if you must go wireless, it should be a very strong connection. The therapist can terminate a telehealth session if it is determined that a stable telecommunication connection cannot be adequately maintained.
• Your computer may have problems that preclude a telehealth session. You are strongly encouraged to make sure you have the latest operating system and security updates, including installation of current and up-to-date antivirus and internet security software, installed on the computer or smartphone you want to use for telehealth sessions. Again, the therapist can terminate a telehealth session if it is determined that a stable telecommunication connection cannot be adequately maintained.
• The session may not be secure or confidential unless you make it so. The therapist will be in a private office for your security and confidentiality, so it is encouraged that you locate yourself in a place that you know is private and secure. Therefore, initiating a session at the beach, a park, or Starbucks is neither private, confidential, nor secure.
• Crisis support services may not be available where you are currently residing or in your geographic area. If you are in a state of crisis and you have no place to get help, there is little a therapist can do from across the wire. The therapist is responsible for identifying resources in your area based on your address (assuming you have one), but it is entirely up to you to access and utilize those resources.
• There is a a number of things a therapist CANNOT see during a telehealth session. From a tiny, fifteen-inch, two-dimensional image, there is significant information that a therapist can miss. Noteworthy mannerisms, gestures, body language or expression, physical appearance, grooming, or dress are just a few marks of data that can be missed in a telehealth session.

This information could be very helpful to your progress in treatment.

I was also notified that all material discussed during the therapy sessions is confidential and can be released only with the permission of the holder of the privilege. I have been informed of the limitations to confidentiality in the Office Policies form, which I have read and signed.

In case of a minor, special sensitivity may be required in releasing information about certain topics such as drugs and sex. I will accept Jeanine Austin Stotts therapist's judgment in regard to releasing or sharing information obtained during the course of therapy with the minor that may endanger or jeopardize the patient's well being.


My signature below grants my consent to the above.

I hereby authorize Compassion Centered Therapy for Women LLC to take photographs of my artwork. I understand that the intentions of these photographs are for therapeutic processing purposes and my rights to privacy and confidentiality will not be surrendered by granting permission for photographs and documentation of my artwork to be taken. I understand if the artwork is to be displayed or used for clinical outreach purposes, that my name and identifying information will remain anonymous and be protected by Compassion Centered Therapy for Women LLC. I understand that this consent is voluntary and whether I choose for my artwork to be photographed, will not affect my relationship with or services rendered by Compassion Centered Therapy for Women, LLC.


I have read the above, have understood it, and agree to the terms.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provided or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agerncy reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or for questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprisesvoluntary and whether I choose for my artwork to be photographed, will not affect my relationship with or services rendered by Compassion Centered Therapy for Women, LLC.


I have read the above, have understood it, and agree to the terms.

In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for an Executor to inform you of my status and ensure your continued care in accordance with your needs. Please let me know if you would like the names of my Executor and alternate Executor. You authorize the Executor and Secondary Executor to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice, such as coma or death.
I have read the above, have understood it, and agree to the terms.

Please note, your treatment plan is always available to you in the TherapyNotes Portal if you need to release your own information to legal counsel.


$2000.00 dollars per day flat rate to include the following in order to avoid conflict, to ethically cover time and to be fairly compensated include the following items:

• Time
• Missed session fees should as I have to cancel sessions to appear in court
• Postage and shipping if needed
• Court prep time
• Mileage, Air travel
• Special considerations (child care, interrupting a vacation)
• Court prep fee if you work with a legal professional who specializes in helping prepare therapists to appear in court
• Hotel fees if appearances are out of state or far from Phoenix, Arizona
• All fees will be doubled if therapist is on vacation