• -25 Years of Clinical Experience
  • -PhD Counseling Psychology
  • -Licensed Mental Health Counselor
  • -Certified Addictions Professional
  • -Qualified Supervisor
  • -Expert Witness
  • -Trauma / PTSD Specialist
  • -Marriage Counseling/ Couples Counseling

Informed Consent Form

and Fees…..

Informed consent for a client

Please Read Carefully

Benefits:
Psychotherapy can have many benefits. It can help you learn to communicate better in your relationships, feel more connected to the important people in your life, create a sense of hope and direction in your life, relieve feelings of  rustration, depression, or anxiety. It can help give you the tools to change your thinking, behavior and feelings to create positive outcomes in your life. You will determine the nature and amount of change you wish to make.

Risks:
In psychotherapy, major life decisions are sometimes made, including decisions involving separation with families, development of other types of relationships, changing employment settings and changing lifestyles. The decisions are a legitimate outcome of the counseling experience, as a result, of an individual’s calling into question many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experience may be too intense to deal with at times. I will be available to discuss any of your assumptions or possible negative side effects in our work together.

Records:
I am required by law to maintain records of each time we meet or talk on the phone. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply. Also, in order to file for insurance reimbursement, I have to assign you a diagnosis. If you have any questions about this, we can discuss together.

Confidentiality:
With very few exceptions, the information discussed during your therapy session and all documentation (written or in any other medium) is kept private and confidential.  Some very important exceptions to this rule are: If there is a court order for the therapist to appear, or to produce the client’s record. If your insurance company is involved, some information will be given after you sign the release of information part off the insurance form. If the therapist learns that there exists a serious threat to any person, including yourself. If there is evidence or suspected child, dependent adult or elder abuse.

Time:
Sessions are 45 minutes long, starting on the hour and ending 15 minutes to the next hour. Longer sessions can be scheduled if we agree that it will be helpful.

Fees:
My standard fee is $175.00 per session.  I accept checks, cash and all credit cards, please note if you choose to use a credit card there will be a fee charged for processing ( typically about $5).

Insurance:
I will provide you with the necessary forms each month that you can submit to your insurance company. The amount of reimbursement and the amount of any co-pays or deductible depends on the requirements of your specific insurance plan. You should be aware that insurance plans generally limit coverage to certain diagnosable mental health conditions. You should also be aware that you are ultimately responsible for verifying and understanding the limits of your insurance coverage. Although I am willing to assist your efforts to seek insurance reimbursement, ( I will provide an invoice),  I am unable to guarantee whether your insurance will provide payment for the services provided to you. Please know that for the sake of determining insurance coverage, the services rendered will be Outpatient Mental Health, and my license is an LMHC (Licensed Mental Health Counselor). Please discuss any questions or concerns that you may have.

Cancellation Policy:
I will be reserving the time for you, so please give me as much notice as possible if you will not be able to make your appointment. My voice mail(561) 585-8787 is available 24 hours a day to receive messages. If you do not provide at least 24 hours notice of a cancellation, you agree to pay the full fee ($175.00) for a missed session.

Ending Therapy:
Your participation in therapy is voluntary and you have the right to end therapy whenever you want. However, if you do decide to exercise this option, I encourage you to talk with me about the reason for your decision in a counseling session together. I ask that you allow at least, one final session for us to have an ending together, to review what we’ve done and to offer feedback to each other. Likewise, at my discretion, I reserve the right to end our therapy work together and provide you with some appropriate referrals, for reasons including, but not limited to, failure to participate in therapy, conflicts of interest, untimely payment of fees, or my belief that I may not be the best person for your needs.

Informed Consent Form
I/we have read, understand and agree to the information and policies described in the Informed Consent Form.

I/we have read, understand and agree to the cancellation policy.

I/we understand that if I/we miss a scheduled session and I/we do not provide at least 24 hours notice or if the absence is not due to a hospital emergency, I/we agree to pay the full payment ($175.00) or applicable co-pay for the missed session.

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Leslie A. Zebel, PhD, LMHC, CAP, Psychotherapist

  • Leslie Zebel PhD,LMHC,Psychotherapist
  • 7401 South Olive Avenue
  • West Palm Beach, Florida 33405-5039
  • Call(561)585-8787
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