Initial fee of $125, subsequent individual sessions $125, couple/family session $125 when billing insurance are due at the beginning of each session. Cash or personal checks to Yvonne Tejeda, PLLC, debit or credit cards are acceptable for payment. There is a $35 fee for returned checks. Please note that fees are subject to change and negotiated before payments are due. Clients or Guardians are responsible for full payment of fees, regardless of insurance company policies. Clients are responsible for notifying this office when their insurance changes, and following through with their insurance account adjustments. Consistency is an important part of the counseling process, and the appointment time that you schedule is reserved for you; it is not available to anyone else. Once an appointment has been scheduled, you will be expected to pay for it unless you provide notice of cancellation at least 24 hours in advance or were unable to attend due to circumstances beyond your control. Messages received on my answering system or text message are acceptable for prior notice. Sometimes it may be necessary for me to reschedule an appointment and I will make every effort to contact you in advance to do so. A fee of $75 will be assessed if short cancel or no show is avoidable. Professional services such as consulting, talking with attorneys or other providers, creating treatment summaries, or records preparation are $75 payable prior to services delivered. I require a $500 retainer prior to action for legal documents or court appearances. I do not accept gifts. Copies are $1 per page.

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask your therapist any questions that you may have regarding its contents. Your therapist is a licensed professional counselor in state of the Texas.

The fee for service is $125 per individual, marital, or family therapy session unless otherwise agreed upon. Regular sessions are 50-60 minutes in length though a longer session can be arranged for an additional charge. You are responsible for fees at the time services are rendered. In certain cases, a written agreement that specifies an alternative payment procedure can be determined.

Cancellations & Missed Appointments
If you are unable to attend a session due to illness or an emergency, please notify me as far in advance as is possible. Since scheduling an appointment involves the reservation of time specifically for you, a minimum of 24-hour notice is required for rescheduling or cancelling an appointment. You will be responsible for the full fee for missed sessions and cancellations within 24 hours of your scheduled appointment. If you are late for your appointment you will be charged your assessed fee and the appointment will end at the scheduled time. Fees for no-shows and cancellations without 24 hours notice are paid at the next therapy session.

Health insurance often provides some coverage for mental health services and I encourage use of all your resources to pay for therapy. If I am not an in-network provider for your insurance, In this arrangement, you are responsible for full payment of my fees rather than your insurance company.

All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that your therapist utilizes a “no-secrets” policy when conducting family or marital/couples therapy. This means that if you participate in family, and/or marital/couples therapy, your therapist is permitted to use information obtained in an individual session that you may have had with him or her, when working with other members of your family. Please feel free to ask your therapist about his or her “no secrets” policy and how it may apply to you. In addition, periodic consultation with peers regarding specific case questions is an accepted and important part of psychotherapeutic practice in order to give you the best care. All information is kept confidential and anonymous. Please let me know if you have concerns about this.
There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder abuse. Therapists may be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the patient that the FBI sought or obtained the items under the Act. All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. Please see the “Notice of Privacy Practices” for more information and a detailed listing of the exceptions to confidentiality.
Minors and Confidentiality
Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, your therapist, in the exercise of his or her professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker. Patients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their therapist.

Therapist Availability/Emergencies
I am often not immediately available by telephone. While I am usually in my office during regular business hours I will not answer the phone when I am with a client. When I am unavailable my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician, the 24/7 Crisis Hotline at 472-HELP, 9-1-1, or the nearest emergency room. If I will be unavailable for an extended time I will provide you with the name of a colleague to contact if necessary.

Electronic Communication and Consent for Use
Be advised that the use of email, cell phone texting, and other forms of technology in psychotherapy may have security concerns and have not been defined as a best-practice strategy.
Any information exchanged electronically or with the use of technology increases the risk of confidentiality breaches. Communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Therefore, the therapist cannot guarantee protection from unauthorized attempts to access, use, or disclose personal information exchanged electronically. Do not include personal identifying information such as your birth date, or personal medical information in any emails you send.
Email/texting communication with Yvonne Tejeda, LPC will be used for the purpose of simplifying and expediting scheduling/administrative matters only. You should also know that any electronic communication I receive from you and any responses that I send to you may become a part of your legal medical record.
Email/texting communication is NOT to be used to provide/receive treatment services or take the place of therapy sessions. Therefore, email/texting should NOT be used to communicate: Suicidal or homicidal thoughts or plans, urgent or emergency issues, serious or severe side effects or concerns, or rapidly worsening symptoms. In a life-threatening emergency clients should: Call 911, proceed to the nearest hospital emergency room, and/or call a crisis hotline such as 512-472-HELP or 1-800-SUICIDE.
No one can diagnose your condition from email or other written communications, and communication via a website cannot replace the relationship you have with your mental health practitioner. The use of email, cell phone, or other forms of technology does not change the fact that the service provided by Yvonne Tejeda, LPC are weekly psychotherapy sessions scheduled and confirmed by both parties in advance of the sessions. Yvonne Tejeda, LPC does not provide crisis intervention, and email/cell phone texting is not a reliable way of obtaining urgent help from the therapist in an emergency.
I have thoroughly considered all of the above information. By signing the Client Information form I consent to the use of email/cell phone texting as needed for scheduling and administrative purposes only, within the guidelines above. If more urgent help is needed, I will utilize the crisis services listed above. Furthermore, if at any time my therapist or I believe email/texting is interfering in my therapeutic process or being used ineffectively, either of us can revoke this consent verbally, refuse to respond to emails/texts, and insist upon a verbal conversation before proceeding.
Litigation Limitation
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney,nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of psychotherapy records be requested.

About the Therapy Process
It is your therapist’s intention to provide services that will assist you in reaching your goals. Based upon the information that you provide and the specifics of your situation, your therapist will provide recommendations to you regarding your treatment. Therapists and patients are partners in the therapeutic process and you have the right to agree or disagree with your therapist’s recommendations and your feedback regarding your progress is strongly encouraged. Due to the varying nature and severity of problems and the individuality of each patient, your therapist is unable to predict the length of your therapy or to guarantee a specific outcome or result.
It is my hope to resolve any misunderstandings that may arise by discussing them with you. Working through such difficulties is one of the most effective ways to grow psychologically and emotionally. Nevertheless, should you have a complaint that you cannot resolve by talking with me or that you do not care to discuss with me, you have the right to call the Texas State Board of Licensed Professional Counselors, 1 (512) 834-6658.

Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination, in collaboration with your therapist. Your therapist will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or your therapist determines that you are not benefiting from treatment, either of you may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.

There are potential benefits and risks to tele-conferencing (ie limits to confidentiality) that differ from in-person sessions.
• Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).
• We agree to use the video-conferencing platform selected for our virtual sessions, and the Yvonne Tejeda, LPC will explain how to use it.
• You need to use a webcam or smartphone during the session.
• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.
• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
• We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
• If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.
• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
• As your licensed professional therapist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.

Client signature/date

Yvonne Tejeda, LPC