Patient Name *

First Name

Last Name

Patient Phone *

(###)

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Contact *

When and how should we contact you? Please check all that apply.

Morning

Afternoon

Evening

Phone

E-mail

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Date of Birth *

MM

DD

YYYY

Partner Name

First Name

Last Name

Partner Phone

(###)

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Primary Care Doctor *

First Name

Last Name

Doctor's Phone Number *

(###)

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Nearest Relative or Friend *

First Name

Last Name

Relative or Friend's Phone Number *

(###)

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Phone Number *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Account Holder *

This is typically the person who receives the insurance through their employer.

First Name

Last Name

Account Holder's Date of Birth *

MM

DD

YYYY

Authorization to Release Information and Assignment of Insurance Benefits *

I authorize Mona Gobrail LLC, and any company designated to provide billing services on their behalf, to: 1) Furnish my insurance company with any and all information requested concerning my claims, 2) bill my insurance company and accept payment from that company on my behalf for all services relating to my care, and 3) if applicable, provide treatment for my minor.

Responsibility *

I alone, and not my health insurance provider, am responsible for all therapy fees.

Cancellations *

I must attend all therapy sessions, or at minimum give 48 hour notice that I need to cancel or reschedule my appointment. Failure to give notice 48 hours in advance will result in a cancellation fee up to the full cost of the session. Two consecutive cancellations will result in a reassessment of the patient's commitment to therapy and may, at the therapist's discretion, lead to a cancellation of counseling service.

Expectations and Results *

While my therapist will provide competent professional counseling that is appropriate for his/her level of training and experience, there is no guarantees of success in this line of work. Although many people improve with counseling, some simply do not. I may experience emotional distress, especially while retrieving and recalling painful memories. For marriage counseling, some will find that therapy will strengthen their marriage, but others may find that their relationship should no longer continue.

Confidentiality *

While confidentiality is the general rule when it comes to therapy, there are specific exceptions that I have been made aware of: 1) Supervisor/Case Conference (to ensure the highest level of care, many therapists regularly meet with supervisors and/or colleagues to discuss cases in clinical conferences); 2) Potential Harm (if a therapist determines that I pose a danger to myself or others, she may provide information about me to my physician, the police, or to any potential victims); 3) Child Abuse Neglect (State law typically requires my therapist to report any suspected child abuse or neglect to child welfare services); 4) Court Cases (in certain limited instances therapists may reveal information learned in sessions if ordered to testify in court or when records are ordered to be turned over to the court); 5) Insurance (some insurance providers require diagnosis and treatment information in order to process claims). I understand that my therapist, within the limitations listed above, will do everything in their power to keep all information discussed in therapy confidential.

Records *

My records will be filed by my therapist for five years, after which time they will be destroyed. These records are confidential and may include notes, diagnosis, or other documents pertaining to my therapy.

Ethical and Professional Standards *

My therapist will adhere to the standard of ethical and professional conduct established by the American Counselors Association (ACA). You can obtain a copy of the ACA Code of Ethics at: http://www.counseling.org/knowledge-center/ethics

Emergencies *

We do not provide emergency services. If you need emergency services, contact your nearest hospital emergency room. However, we encourage you to call us after you contact and/or go to the emergency room so that we can provide support. If you feel the need to contact your therapist at an unscheduled time, we can provide a virtual session to meet your urgent needs.

Inclement Weather *

The therapist will notify any scheduled patients of any office closing or session cancellation. Generally, if the office parking lot has been cleared of snow or ice, then the office will remain open and any missed sessions will be billed per the Cancellation Policy

Unattended Children *

Our office space does not provide childcare during counselling sessions. No patient or accompanying visitor may leave a child unattended in our offices at anytime. Unless a family session is scheduled in advance, children may not attend during an adult's therapy session. Please plan to bring along an adult to supervise your children during sessions or find a daycare provider for the time that you spend during a session.

Limit of Liability *

I agree to limit Mona Gobrail LLC's liability to the amount paid out of pocket for my therapy sessions. This limit of liability extends to the furthest legally allowable limitations, including, but not limited to, negligent and intentional actions. Where such limits of liability would be deemed unallowable, this agreement shall limit liability to the highest allowable level. The amount paid out of pocket by me for my therapy sessions shall be the maximum liquidated damages to be paid by Mona Gobrail LLC.

Binding Arbitration *

In the event that a conflict arises between myself and Mona Gobrail LLC, I agree to binding arbitration in the State of Maryland to be chosen by Mona Gobrail LLC. Attorneys' fees shall be the responsibility of each party. Mona Gobrail LLC will not be liable for my attorney's fees.