Hello and welcome to my practice. Please read the information below and then click on the link and you will go to the questionnaire. The
confidential questionnaire will help me understand who you are as a unique individual and what you are seeking from therapy. We will go
over this information in more detail when we meet. After completing the form on the next page please press the Submit button and the
information will come directly to me. Directions to my office will pop-up for you to print out after submitting this form. This information will take
about 15-20 minutes to complete.
PAYMENT AND APPOINTMENT INFORMATION (Please Read Carefully)
A. Fee Schedule:
*When discounted sessions are paid in advance, any unused sessions are refundable at your request; however, the used sessions are
then reverted to the highest individual rate. Unused sessions can be used at anytime during the future, transferable to a person of your
choice or refunded at your request.
B. Payment for Services:
Payment is due at the time services are rendered and may be paid by check, cash, credit card or debit card. A non-
refundable $100 initial appointment deposit is required before the first session and can be paid by credit card or debit
card after completing the questionnaire. This amount will be deducted from your initial intake fee. You will be given a
receipt that is accepted by most insurance companies for reimbursement directly to you. When you enter your credit card
information, you will not be charged for any session until after the session.
C. Keeping Appointments:
Each therapy session is about 55 minutes. The last few minutes are generally reserved to review the session and
schedule any further appointments. Sessions cancelled less then 24 hours or failure to show for appointments are
charged full fee. If I fail to show or have to cancel on the day of our appointed time I will pay you $25.
D. Confidentiality:
You have a right of confidentiality that is covered by law. This means that the material you share with a therapist may not
be revealed to anyone unless you give your written permission. There are, however, particular conditions in which a
therapist is obligated by law to break confidence and report certain incidents to the authorities. These are: 1) Subpoena
by a judge in a court of law, 2) If you have abused or molested a child or elder adult or if you reveal that such incidents
have occurred by others, 3) If you indicate that you intend to harm or kill yourself or someone else.
90-minute Initial Assessment: $225
60-minute session: $190
Discounts:*
4 sessions paid in advance: @$180
6 sessions paid in advance: @$170
8 sessions paid in advance: @$160
10 sessions paid in advance: @$150
Hypnosis sessions: $195
Group Therapy: $280/per month
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Kimberly DeLamar, M.A. M.F.T.
60-Minute Session: $120
Mary Curtis, CCH
75-Minute session: $100
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