Professional Disclosure Statement

Jenn Pagone, LCPC (IL), LPC (WI)

Pagone Psychological Services, PLLC at Whispering White Horse Stables, LLC

p 773.339.7949 / f 847.660.7997

jennpagone@yahoo.com / www.pagonepsychologicalservices.com


Therapist-Client Consent for Services Agreement

Welcome to Pagone Psychological Services, PLLC. This document contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), the federal law that provides new privacy protections and new patient/client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that you are provided with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail. The law requires your signature acknowledging that I have provided you with this information (this information is both electronically on my website and in printed form in my office). Although these documents are long and sometimes complex, it is important that you read them carefully. Please feel free to discuss any questions you have with me about the contents in this Agreement and the Notice. Your signature on page 7 of this document and signing the “Signature Page” will represent an agreement between us.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. The methods I choose depends on the collaborative goals we set as a team. During your therapeutic process we will discuss these methods, interventions and strategies so you understand the specific goal for them. Together we will find the best ways to address the issues you are facing. Psychotherapy calls for an active effort on your part and therefore is most successful when you work on things we talk about during our sessions and outside of sessions.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, and anxiety.  On the other hand, psychotherapy has been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.  However, there are no guarantees of what you will experience. It is important that you discuss your expectations of therapy with me and continue to have a dialogue about what is helping and what is not. It is very important to express any negative reactions with your therapist in order to quickly resolve any issues that may arise.



I earned my graduate degree in Clinical Professional Psychology from Roosevelt University. I am licensed in Illinois and Wisconsin and utilize an empowering and authentic approach to assist clients in identifying core issues and learn how to express their thoughts and feelings beneath the symptoms with which they struggle. The ultimate long-term goals are healing, improve functioning and developing a solid, secure attachment and connection within the self and with others.

Various treatments and interventions are offered for those suffering from a wide range of psychological issues such as complex and developmental trauma, grief and loss, attachment challenges, somatization issues, eating disorders, perinatal mood disorders, marital dissatisfaction, and depression and anxiety. Treatment goals are collaboratively determined through a variety of options and with constant consent. One of my guiding principles is that I believe the client is an expert on themselves as I facilitate the psychological exploration; somewhat of an “archeologist of the mind”.

Prior to opening my private practice, I gained experience working as a rape crisis counselor and medical advocate, and as a clinical therapist on inpatient and outpatient behavioral health hospital units, as well as a program coordinator in residential program.

Throughout my career I have pursued continuous training in order to provide the most up-to-date and empirically sound treatment interventions to support my clients in their healing journeys. My passion for learning has allowed me to integrate various treatment modalities well beyond the scope of traditional clinical psychology foundations. However, my greatest teachers have been my patients and clients over the past decade. 


Therapy approaches include psychodynamic and attachment theories, Eye Movement Desensitization Reprocessing (EMDR) (Certified), Somatic Experiencing (SE), Internal Family Systems (IFS) and parts work, clinical hypnotherapy, and “Equid-Nexus, an equine engaged parts work psychotherapy”. Other modality/interventions include meditation, relaxation and stress reduction techniques, sound therapy, breath work, and spiritual oriented processing.

All treatments are informed by trauma neurobiology. Focused attention is given to regulating certain regions of the brain and nervous system to promote healing and integration at the deepest level. This foundation is utilized with all clients regardless of the presenting problem. Instead of learning cognitive coping skills neurobiology interventions target the very root of dysregulation regardless if the client is experiencing anxiety, depression or a severe stress reaction.



What you can expect from the first few sessions is a review of your background; the information you feel important to share with me in order to help better understand you and your needs, me gathering other information pertinent to why you are seeking therapy, and getting a well-rounded picture of you and the roles you play in your life and those in it. You will be asked to read this document in its entirety and sign the “Signature Page” indicating your agreement with the terms presented in this document.

Our first few sessions will involve an evaluation of your needs, after which I will offer you some first impressions of what our work will include and discuss a treatment plan.  During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals.  You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be selective about the therapist you choose. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

You are responsible for scheduling your own sessions using TherapyAppointment.com. Appointments are typically 45-55 minutes in length. Depending upon what we are working on sessions may be longer. It is important that these longer sessions are scheduled accordingly and prior to the appointment. If your session runs longer the charge is $65 dollars per half hour. This fee is not covered by insurance companies and will be due the day of your appointment.

I strive to remain on-time with scheduling. Please be on time. Note that due to the nature of the therapeutic process some sessions will unpredictably go over the allotted time limit. I honor and respect each and every client’s process and at times a few minutes are needed to close a session properly. Please be patient if this occurs. If I am running late, please do not exit the waiting room and knock on my office door. I appreciate your patience.

Excluding special circumstances and due to the scheduling of others’ appointments, I am usually unable to extend past the usual end time. Therefore your full fee will be due even if you are late. However, if I am running late, I will either prorate your session fee (if possible, given your payment situation) or extend the time. On each appointment you will be expected to pay the fee or copay/coinsurance. This will occur during your session time. Payments are accepted by cash, check, credit or debit card, Zelle (jennpagone@yahoo.com) or Venmo (@Jenn-Pagone). There is a $2.50 convenience fee for debit and credit cards under $100. The convenience fee for amounts over $100 is $5.00 per transaction. Fees are collected and put into the system immediately. An encrypted emailed receipt can be sent upon request.

If you need to cancel an appointment, please do so at least 24 hours in advance.  You will be charged $50.00 for appointments cancelled with less than 24-hour notice, and be charged $75 for same day cancellations, unless we both agree that you were unable to attend due to circumstances beyond your control.  Please be aware that insurance companies do not provide reimbursement for cancelled sessions..  If it is possible, I will try to find another time to reschedule the appointment.  If there is a pattern of cancellation of appointments and/or cancelling under 24 hour notice, I reserve the right to limit the number of appointments booked at one time or restrict online access altogether. If two months’ time lapse between appointments without discussion your status within the electronic system will change from active to “inactive”. You may re-active your account at any time by contacting me to do so.


The fee for the initial evaluation appointment is $175.  My standard fee for 55-minute sessions is $140, however under certain circumstances a sliding scale fee may be used at my discretion. My fee for clinical services beyond the scheduled appointment is $140/hour, $65/half hour. Again, please note that most insurance companies do not pay for anything over the scheduled session time. You will be responsible for the balance out of pocket.  

I believe in coordinate of care with your other providers, such as psychiatrists, dieticians, school counselors, etc. therefore I provide these occasional services free of charge. However, should you become involved in a divorce or custody dispute, or any other legal matter, I will not provide evaluations or expert testimony in court. Your signature indicates your agreement with this provision.



I am engaged and provide my full attention to each client and therefore do not answer the phone while I am in session. I will make every attempt to check my voicemail or other messages between sessions.  I will return your non-emergency call within 24 hours, with the exception of holidays. If you are difficult to reach, please inform me of times when you will be available. Should you need to email me with sensitive information, please email me through therapyappointment.com as this is secure and encrypted. I do not accept texts as they are not secure. Instead, I use a free encrypted texting app called Signal. If you are interested in using this free app I provide you with a release form.

In addition, please do not call or email me in cases of emergencies. I am not an on-call clinician. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or 911 or go to your nearest emergency room and ask for the therapist and/or psychiatrist on call.  If I will be unavailable for an extended time, I will provide you with the name and phone number of a colleague to contact, if necessary.



The law protects the privacy of all communications between a patient and a therapist. In most situations, if you are 18 years of age or older, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and Illinois law. However, there are several situations in which no authorization is required.  Examples are listed below.  Please see the HIPAA Privacy Notice on page 8 for details and website link for more information.

Consultation with other health or mental health professionals
Teaching and supervision
Malpractice suits or complaints
Judicial and administrative proceedings (e.g., if you are involved in court proceedings)
Workman’s Compensations claims
Government/Health Agency oversight
Health Insurer payment or collection on overdue fees

Therapists are mandated reporters.  As such, there are some situations in which I am legally obligated to take actions in order to protect you and others from harm.  If these circumstances arise in the course of your treatment, I may be required to reveal information about you or your treatment without your specific authorization.  If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

Exceptions to confidentiality:

If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I report this to the local office of the Department of Children and Family Services.

If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I report this to the agency designated to receive such reports.

If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you, such as friends or the police.

If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you have now or arise in the future. The laws governing confidentiality can be complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.


PROFESSIONAL RECORDS (HIPAA Privacy Notice is located on page 8 of this document.)

All information client and clinical information, both paper and electronically, is kept according to HIPAA. For all clients, I keep a Clinical Record that includes information about reasons for seeking therapy, diagnosis, treatment goals, progress towards goals, medical and social history, treatment history, past treatment records received from other providers, professional consultations, billing records, and any prepared reports, including those to insurance carriers.  In addition, I may also keep Psychotherapy Notes, which are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary, they can include the contents of conversations, my analysis of conversations, and how they impact treatment. They may also contain sensitive information revealed to me that is not required to be included in your Clinical Record. These Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of Psychotherapy Notes without your authorization.  Both sets of records can be misinterpreted and/or be upsetting to untrained readers. For this reason, if you request to review them, I recommend that you do so in my presence, or have them forwarded to another mental health professional to discuss their contents. In most circumstances, I am allowed to charge a copying fee of $2 per page.



HIPAA provides you with several rights with regard to your Clinical Records and disclosures of PHI. These rights include requesting amendments to your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; having any complaints you make about policies and procedures recorded in your records; and the right to a paper copy of this Agreement and Notice of Privacy Practice. I am happy to discuss these rights with you.



Patients under 13 years old and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 13 and 18 cannot examine their child’s records unless the child consents and I find no compelling reasons for denying this access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed.  Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 13 and 18 years old and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, I will provide parents with general information about the progress of their child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. 



As mentioned above, you will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.  If such legal action is necessary, its costs will be included in the claim.



In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment.  However, you (not your insurance company) are responsible for full payment of fees. It is important that you carefully read the section in your insurance coverage booklet that describes mental health services.   As well, it is recommended that you call your insurance company to find out exactly what mental health services your insurance policy covers. Both the client and the person (spouse or parent) who is the primary insurance carrier that the client is covered under MUST sign the Signature Page indicating your compliance.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services or limit the number of session available.  It may be necessary to seek approval for more therapy after a certain number of sessions.  There are no guarantees that such requests will be granted.  Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described.

Health insurance companies require that you authorize me to provide relevant information regarding rendered services.  If you seek reimbursement for services through your health insurance company, your signature on the Signature Page will indicate the authorization which allows me to provide such information, including a clinical diagnosis. Sometimes I am required to provide additional information such as treatment plans or summaries.  I will make every effort to release only the minimum information necessary. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands.



As in every relationship there are bound to be connection and attachment ruptures. Due to the nature of the in-depth clinical psychotherapy process we sometimes re-enact old unhealthy relationship patterns. Part of the healing process is changing these unhealthy interpersonal patterns, which requires consistent communication, honesty, and trust, all while being held in a safe therapeutic space. Repairing a rupture in a relationship is a hallmark of secure attachment. I believe that every rupture in a relationship is ripe therapeutic material to aid in healing and attaining secure attachment. I uphold the highest ethical standards put forth by the American Psychological Association. You can expect me to work diligently on our therapeutic relationship as a vehicle for lasting change. The goal is for you to join me in any conversations needed about the status of our therapeutic relationship, or your perceptions and feelings you need to share. However, should you feel that after directly discussing any important issues that you need to make a formal complaint against my license about my therapeutic services, please contact the below Departments of Professional Regulation. My hope is that we can work to repair any ruptures so formal actions are unnecessary.


State of ILLINOIS Clients

As in accordance with the State of Illinois, the following information is provided to you should you wish to file a formal complaint against my counseling services (State of Illinois | Department of Financial & Professional Regulation (idfpr.com):

Mailing Address for the IDFPR Complaint Intake Unit:

Department of Financial and Professional Regulation
Division of Professional Regulation
Complaint Intake Unit
100 West Randolph Street, Suite 9-300
Chicago, IL 60601
Phone: 312/814-6910


State of WISCONSIN Clients

As in accordance with the State of Wisconsin, the following information is provided to you should you wish to file a formal complaint against my counseling services (DSPS File A Complaint (wi.gov)):

Wisconsin Department of Safety and Professional Services
Division of Legal Services and Compliance
P.O. Box 7190
Madison, WI 53707-7190

Fax: (608) 266-2264

Email: dsps@wisconsin.gov


My signature below indicates that I have received, reviewed, read, and understand this document, the Professional Disclosure Statement and Client-Therapist Services Agreement. If I am unclear about anything in this document, I understand that Jenn Pagone, LCPC, LPC will discuss any questions or concerns I may have. My signature indicates that I have been provided with the HIPAA Privacy Notice. I understand that by signing this document I agree to abide by the Agreement. I also understand that I can rescind this agreement at any time in writing.

First Clients Name

First Name*

Last Name*

First Clients Age Acknowledgment*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Signature*
Second Clients Name

First Name*

Last Name*

Second Clients Date of Birth*
Second Clients Signature*
Third Clients Name

First Name*

Last Name*

Third Clients Date of Birth*
Third Clients Signature*
Fourth Clients Name

First Name*

Last Name*

Fourth Clients Date of Birth*
Fourth Clients Signature*
Fifth Clients Name

First Name*

Last Name*

Fifth Clients Date of Birth*
Fifth Clients Signature*
Sixth Clients Name

First Name*

Last Name*

Sixth Clients Date of Birth*
Sixth Clients Signature*
Seventh Clients Name

First Name*

Last Name*

Seventh Clients Date of Birth*
Seventh Clients Signature*
Eighth Clients Name

First Name*

Last Name*

Eighth Clients Date of Birth*
Eighth Clients Signature*
Ninth Clients Name

First Name*

Last Name*

Ninth Clients Date of Birth*
Ninth Clients Signature*
Tenth Clients Name

First Name*

Last Name*

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


Confirm Email*
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*


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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