| Cort Curtis, Ph.D. |
Hello and welcome to my practice. Please read the information below and then enter your name and email address to receive a link to
the Intake 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.
PAYMENT AND APPOINTMENT INFORMATION (Please Read Carefully)
A. Fee Schedule:
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.
the Intake 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.
PAYMENT AND APPOINTMENT INFORMATION (Please Read Carefully)
A. Fee Schedule:
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.
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