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Jenn Pagone, LCPC

Pagone Psychological Services, PLLC

Therapist-Client Services Agreement Signature Page

 Jenn Pagone, LCPC

Pagone Psychological Services, PLLC

p 773.339.7949 / f 847.660.7997 / jennpagone@yahoo.com / www.pagonepsychologicalservices.com

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Therapist-Client Services Agreement & Notice of Privacy Practices

SIGNATURE PAGE

Your signature below indicates that you have read the Therapist-Client Consent for Services Agreement / Professional Disclosure Statement and the Notice of Privacy Practices. These documents are electronically located on my website (https://www.pagonepsychologicalservices.com) with a hard copy (which you may view at any time) in my office. It is your responsibility to read them in their entirety as you will be held accountable for their contents, policies and procedures. In addition, your signature indicates that you agree to abide by the terms stated in these documents as well as the below bullet pointed items. 

The Therapist-Client Services Agreement/Professional Disclosure Statement and the Notice of Privacy Practices represent an agreement between you and the psychology practice of Jenn Pagone, LCPC (Pagone Psychological Services, PLLC). You may revoke this agreement at any time in writing. Furthermore, revoking or breaking these agreements will result in termination of the professional services provided to you by Jenn Pagone, LCPC (Pagone Psychological Services, PLLC ).

I Agree
Please note that if you have a lapse in therapeutic services for one (1) month your account will go inactive and you will lose the ability to electronically schedule sessions. Should you wish to return for therapeutic services please contact me to re-activate your account (however there is no guarantee that space will be available to accommodate your return). Since you are responsible for scheduling your own appointments, I will assume that you no longer need my services if you do not have any appointments scheduled for a month. Your check mark indicates that you understand that once your account goes inactive you are no longer under my care. Should you decide that you need additional services or would like to change providers and this is the reason that you are not booking further appointments, I am happy to provide you with referrals. It is important that we have an understanding and communicate about these matters.

To highlight specific terms within the Therapist-Client Services Agreement, your signature below and checkmarks indicate that you agree to each of the following:

I Agree
I will schedule my own appointments and understand it is my responsibility for any changes or deletion of appointments. I will abide by the 24 hour cancellation policy and understand that if my appointment is not cancelled and I do not attend my session I will be charged a $85 no show/less than 24 hour cancellation fee. If I cancel my appointment on the same day I will be charged $100.00. Cancellation fees are not covered by insurance. Cancelation fees will be paid with the credit card on file. I am aware that my account is set up to receive session notification reminders over 24 hours prior to each appointment, giving me ample time to cancel if needed. I also understand that if I am 15 minutes or more late to my session without letting Jenn Pagone know I will forfeit my session and be charged the no show fee.

I Agree
I understand that therapy appointments can be changed or modified at any time by Jenn Pagone, and it is my responsibility to stay up to date on all of my scheduled appointments. I understand that I have access to all of my appointments via the Therapy Appointment client portal.

I Agree
I understand that three (3) or more no show appointments (under 24 hour cancellations) within a six (6) week time period, may result in losing the ability to schedule my own appointments and will need to schedule through Jenn Pagone, LCPC. Depending upon the circumstances this may lead to termination from further therapeutic services. At which time I will contact my insurance company for a referral to another provider.

I Agree
I understand that my balance and understanding my insurance policy are ultimately my responsibility, and will pay all co-pays and/or co-insurance and/or deductible on the date of service via the credit card on file. I understand that my credit card will be run after each session.

I Agree
I understand that if I change insurance companies, I am obligated to immediately provide that information to Jenn Pagone, LCPC. Failure to do so will result in owing my complete balance out of pocket and on the date of service. NO Exceptions.

I Agree
I understand that I have full access to my appointments and my account balance, and therefore it is my responsibility to keep my account up to date. I understand that Jenn Pagone, LCPC does not provide monthly statements because this information is readily available to me.

I Agree
I understand that if I am on a sliding scale for session fees I need to pay the full session fee the day of my appointment. Should I cancel under 24 hours I will be charged the full session to my credit card on file.

I Agree
I understand that in case of an emergency I will call 911 and/or go to my nearest emergency room. I understand that Jenn Pagone, LCPC is not an on-call clinician and may not be available to me during a crisis. I also understand that Jenn Pagone, LCPC will make every effort to attempt to meet my needs, but immediate support is not guaranteed.

I Agree
I understand if I need an extended appointment that my insurance company may not cover the extra session time. I understand that I will be charged a $87.50 fee for every half hour, and $175 per extra hour, and fees will be charged to the credit card on file.

I Agree
I understand each session is 55 minutes in length and I will take responsibility to start and end each session on time. I understand that Jenn Pagone, LCPC needs 5 minutes in between session to prepare for her next client. I am aware that my inattention to time impacts Jenn Pagone, LCPC and other clients. I understand that due to the nature of therapy unforeseen emergencies may arise which may impact the length of my session. I understand that my session will not automatically be extended, and may be prorated for actual session time. I also understand that if Jenn Pagone, LCPC has an emergency or needs to cancel for any reason, that she will make an effort to offer me another appointment that week, if possible.

I Agree
I understand that Jenn Pagone, LCPC ultimately determines whether sessions will be in-person or virtual. I understand that if I am booked for an in-person session and it is determined, for whatever reason, that the session needs to be held virtually and I do not wish to engage virtually, I will let her know immediately. I understand that if I cancel my appointment for this reason without previously expressing my preferences prior to my appointment, that I will be charged a cancellation fee.

I Agree
I understand that communicating through text and email are not secure forms of communication and I assume all risks should information be breached. I understand that I may use the encrypted email through my account through therapyappointment.com or through the free and encrypted text app Signal. I am also aware that Jenn Pagone, LCPC uses encrypted forms of telehealth services through a paid version of Zoom with a Business Associate Agreement, and that all attempts are made to ensure safety, but it is ultimately not guaranteed. I understand that alternate forms of connection (eg: FaceTime) for Telehealth sessions is not secure and I assume the risk of choosing this platform.

I Agree
I understand that Pagone Psychological Services, PLLC takes reasonable measures to ensure the safety of my Protected Health Information (PHI).

I Agree
Should I have any complaints about the services rendered by Jenn Pagone, LCPC, or if I feel that there has been a rupture in our therapeutic relationship, I understand that it is my responsibility to bring this to her attention so a repair may be made. I understand that Jenn Pagone, LCPC adheres to the ethical standards of the American Psychological Association, and will be willing to have any discussions needed to repair our relationship, as this is part of the healing process and strengthens interpersonal effectiveness.

I Agree
I understand that in the event my therapeutic relationship with Jenn Pagone, LCPC comes to a close earlier than expected, she will provide me reasonable advanced notice and support me finding another provider to meet my needs.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*

Phone*
Second Client's Date of Birth*
Second Client's Signature*
Third Client's Name

First Name*

Last Name*

Phone*
Third Client's Date of Birth*
Third Client's Signature*
Fourth Client's Name

First Name*

Last Name*

Phone*
Fourth Client's Date of Birth*
Fourth Client's Signature*
Fifth Client's Name

First Name*

Last Name*

Phone*
Fifth Client's Date of Birth*
Fifth Client's Signature*
Sixth Client's Name

First Name*

Last Name*

Phone*
Sixth Client's Date of Birth*
Sixth Client's Signature*
Seventh Client's Name

First Name*

Last Name*

Phone*
Seventh Client's Date of Birth*
Seventh Client's Signature*
Eighth Client's Name

First Name*

Last Name*

Phone*
Eighth Client's Date of Birth*
Eighth Client's Signature*
Ninth Client's Name

First Name*

Last Name*

Phone*
Ninth Client's Date of Birth*
Ninth Client's Signature*
Tenth Client's Name

First Name*

Last Name*

Phone*
Tenth Client's Date of Birth*
Tenth Client's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Date

Today's Date *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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