ABC’s of Play Therapy

Custody Evaluations:

Joyce Meagher, VAPT member, conducted an informative workshop at June VAPT conference. She described best practices and considerations for play therapists conducting custody evaluations or testifying in court. She has permitted VAPT to share a sample contract with its members.

Your Corporate or Office Name
Your personal name
Your License title

Name:	Telephone: Home: Office:
Address:	Emergency Contact: Name: Telephone Number:
Date of Birth:	Insurance Carrier:

COUNSELING AGREEMENT

Confidentiality is maintained as part of the counseling process in accord with generally-accepted ethical standards. The client’s written authorization is required for any release of information or records, including taping of sessions. Exceptions are made to this policy in the event of court order or imminent danger. An exception may also need to be made in the event of nonpayment of fees, necessitating the use of a collection agency. Use of insurance forms to obtain third-party payments serves as authorization of release of information to your insurance company. Please be aware that I cannot guarantee that confidentiality of information released to insurance carriers or other third parties (school counselors, teachers, lawyers, etc.) will be maintained by those agents.

In order to maximize the quality of your counseling and in keeping with typical counseling practices, it is my policy to discuss cases with colleagues in shared consultation; identifying data will be kept at a minimum.

Counseling sessions are generally scheduled once a week for forty-five (45) minutes. Clients are expected to keep appointments as scheduled. If an appointment is cancelled or missed with less than 48 hours notice, the client will be charged for that session. Fees for missed sessions are not reimbursed by insurance companies.

The intake session fee is $___. Fees for weekly services are $___ per 45 minute session, with payment expected weekly. There will be a 10% fee on unpaid balances as of the first of each month (excluding outstanding insurance balances). Telephone consultation will be billed as a session if the call exceeds 15 minutes. Requested written reports will be done at $___/hour. Fees for court appearances will be $____ per day, due 10 days prior to court (This includes travel, preparation time and missed work hours). If court is cancelled with a 7-day notice, $___ will be refunded. Reports are not generally insurance-reimbursable.

Statements necessary for insurance reimbursement will be supplied at the beginning of each month. However, please be advised that insurance companies differ in their policies from 0 - 90% reimbursement for outpatient mental health counseling.

Signature:______________________________
Date:___________________________