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RESPONSIBILITY 

By signing this form, I acknowledge that I have been given a copy of the fee schedule listed below. I understand that I  am financially responsible for all fees for services provided to me or to an individual for whom I am legal guardian.  

FEE SCHEDULE AS OF JANUARY 2026

Self-Pay Clients (in lieu of having us file claims to your insurance) will receive a substantial discount from the following  CPT charges. Self-pay charges are $150.00 for the first session and $130.00 for all sessions thereafter. 

CPT Code Description of Services Fee per Unit

90791 Diagnostic Interview (50 min) $ 245.00 

90832 Individual Therapy (30 min) $ 100.00 

90834 Individual Therapy (40 to 45 min) $ 130.00 

90837 Individual Therapy (50 min) $ 160.00 

90846 Family Therapy (w/o client present) (45-50 min) $ 160.00 

90847 Family Therapy (w/ client present) (45-50 min) $ 160.00 

90839 Therapy for Crisis (first 60 min) $ 200.00 

90840 Therapy for Crisis (each additional 30 min) $ 100.00 

ADDITIONAL FEE SCHEDULE 

Please note these fees are not covered by insurance. Credit cards on file will be charged for these services. 

Description of Services Fee per Unit 

Preparation of Report (45-50 min) $ 160.00 

Phone Call Brief to Therapist (10-15 min) $ 55.00 

Phone Call, Intermediate to Therapist (20-30 min) $ 90.00 

Third Party Correspondence Fee (10-15 min) $ 30.00 

Misc. Services (20-30 min) $ 90.00 

“No Show” Appointment $ 130.00 

Late Cancellation (less than 24 hours) $ 100.00 

Travel (20-30 minutes) $ 90.00 

Court-Related Services(including prep and travel time) (45-50 min) $ 420.00 

PAYMENT: I am required to keep a credit card on file for all charges incurred. A receipt will be emailed to me once charges are processed.  

APPOINTMENTS: If I am unable to keep my appointment, I will provide notification as soon as possible. I understand that if I cancel my appointment without 24 hours’ notice, I will be billed $100.00 for the session. I understand that if I do not show up to my appointment without notifying the provider, I will be billed $130.00 for the session. These fees will be charged to the credit card on file. 

Financial Responsibility Agreement: 

USE OF INSURANCE PLANS: I understand that my insurance coverage, preauthorization requirements and terms of coverage are ultimately my responsibility. Innovative Psychology Counseling Services will verify insurance coverage, supply clients with a good faith estimate and bill my insurance carrier as a courtesy. There are times when insurance websites misquote benefits. In the event of a misquote and/or if the claim is not paid by the insurance company, I will be responsible for all deductibles, co-insurance, and copays as outlined by my insurance provider. This varies per insurance carrier. I am responsible for verifying my service coverage and obtaining any authorization that may be needed. I understand that secondary insurance is not billed by the provider; however, the office will supply an invoice to submit for reimbursement if requested.  

GOOD FAITH ESTIMATE: I am entitled to a Good Faith Estimate for which fees will be disclosed. We are happy to answer any questions about the charges you may incur.  

CONSENT TO TREATMENT: In signing this, I agree to participate in treatment and understand that a positive outcome cannot be guaranteed. I understand that working with my therapist in identifying therapy goals is my best interest, and I  agree to be an active participant in working towards these goals. I also understand that there are some instances in which therapy could worsen my symptoms, and participation does not guarantee that my symptoms or concerns will be resolved. 

CONFIDENTIALITY AND PRIVACY: I have read and agreed to the Privacy Notice (HIPAA Statement) provided to me. I  understand that I can ask for clarification on any policies stated in it or other Innovative Psychology Counseling Services forms. 

EMAIL POLICY: It is our policy to cover the content of therapy during the scheduled therapeutic appointment. Although, the email is privacy protected, we cannot guarantee against a data breach despite the high level of security. If I need additional support in-between sessions, I will contact my provider to schedule an additional session.

GENERAL INFORMATION: Welcome to Innovative Psychology Counseling Services. The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important to have a clear understanding of the therapeutic relationship. This consent will provide a clear framework for our work together.  Please read and indicate that you have reviewed this information.

PSYCHOLOGICAL SERVICES: We provide psychotherapy services to children, adolescents, adults, couples and families.  Therapists and clients will work collaboratively to determine treatment goals and the direction of therapeutic services.  Therapy can be extremely helpful and fulfilling; however, practicing skills during therapeutic sessions and at home is necessary for it to be effective. Therapy requires active involvement, honesty, and openness to change thoughts, emotional reactions, and/or behaviors.  

Psychotherapy can have benefits and risks. In therapy, you may experience an increase in uncomfortable emotions as you self-explore and change relationship dynamics, communication, and boundaries. Potential benefits often lead to better relationships, solutions to specific problems, significant reductions in feelings of distress, and an increase in healthy habits.  

Treatment noncompliance may necessitate termination of therapeutic services. We encourage you to discuss any concerns you have with your therapist directly in order to resolve them in a timely manner. Other factors that may result in termination of services include, but are not limited to, violence or threats toward staff and refusal to pay for services within a reasonable timeframe.  

WHAT TO EXPECT IN THERAPY: The first 1-2 sessions are used to gather client information, identify client needs and determine treatment goals. If the client and therapist decide to engage in therapeutic services, 50-minute sessions will be scheduled. Appointments can take place in the office or virtually, depending on your preference. Frequency and duration of therapeutic services will vary based on specific clinical needs. 

PROFESSIONAL FEES: Our fees are listed in the Financial Agreement. In addition to appointments, we charge for other professional services you may need. Other services include letter and report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time even if we are called to testify by another party. 

CONTACTING YOUR THERAPIST: Your therapists will not be immediately available by telephone. Please leave a voicemail or email your therapist directly and they will within 24 hours. We recommend that email only be used to schedule appointments and exchange limited information. Although, the email is privacy protected, we cannot guarantee data breach despite the high level of security.

In case of an emergency, please contact your family physician, go to the nearest emergency room, call 911 or the McHenry County Crisis Line at 1-800-892-8900.

PROFESSIONAL RECORDS: The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of your records, or we can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in your therapist’s presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. 

MINORS: If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concern. We will also provide them with a summary of your treatment when it is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss. 

CONFIDENTIALITY: In general, the privacy of all communications between a patient and a therapist is protected by law, and we can only release information about our work to others with your written permission, however there are a few exceptions. 

In most legal proceedings, you have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order our testimony if he/she determines that the issues demand it. 

There are some situations in which we are legally obligated to take action to protect others from harm, even if we have  to reveal some information about a patient’s treatment. For example, if we believe that a child, elderly person, or disabled person is being abused, we must file a report with the appropriate state agency. 

If we believe that a patient is threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in our practice. If a similar situation occurs, we will make every effort to fully discuss it with you before taking any action. 

We may occasionally find it helpful to consult other professionals about your case. During a consultation, we make every effort to avoid revealing the identity of our patients. The consultant is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. 

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not attorneys.

This form is for you to supply Innovative Psychology Counseling Services with credit card information to keep on file for the payment of all services and fees. A new form must be completed for each card kept on file. (We do not accept Discover Card.)