New Couple Registration

Personal Information  
Partner 1
Partner 2
Home Address
Second Home Address
Counseling Agreement  

Counseling will be conducted by a Marriage and Family Therapist, Psychologist or MFT Associate supervised by a licensed clinician.

Confidentiality

Information disclosed in therapy is considered strictly confidential and will not be released to any third party without your written authorization, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse, when a patient makes a serious threat of violence towards a reasonably identifiable victim, or when a patient is dangerous to him/herself or the person or property of another.

Session Length & Fee for Services*

A usual therapy session is 50 minutes long. However, in couples counseling, it is often recommended to do a longer session, for example: 75 minutes or 100 minutes. The fee for longer sessions is prorated, unless a different agreement was made with the therapist. The following represents the fee agreement between The Couples Center and you & your partner.

Fees are due each session, payable by debit or credit card. Fees may be adjusted and reviewed periodically. Failure or refusal to pay for services after a reasonable time could lead to termination of services.

Insurance

The Couples Center is not a contracted provider with any insurance company or managed care organization. Should you choose to use your insurance or get reimbursed by a flexible spending plan, your therapist will provide you with a statement that will facilitate reimbursement by your insurance or employer. Note that we are unable to guarantee whether your insurance will provide payment for the services provided to you.

Cancellation Policy

It is important for the continuity of therapy that you come to all sessions. Since your appointment time is reserved exclusively for you, TCC has a usual cancellation policy of 48-hour. Unless discussed and agreed otherwise with your therapist, if you cancel within 48 hours of the appointment time you will be charged for the session.  

Dual Relationships

Therapy never involves sexual, business, or any other dual relationships that could impair the therapist’s objectivity, clinical judgment or could be exploitative in nature. If, during the course of your treatment, the therapist or you become aware of other preexisting relationships that may affect your work together, it is important that those will be discussed and resolved ethically.

Ending Therapy

You have the right to stop counseling at your discretion. We encourage you to discuss your thoughts of termination with your therapist as termination can be a very important part of therapy. Usually, your therapist will recommend that you participate in at least one, or possibly more, termination sessions so you can summarize the work that you've done together.

Therapist Communications

Your therapist may need to communicate with you by phone or email. Sensitive, clinical information should be discussed over the phone or in-person in order to better assure confidentiality. Please note that potential risks of using electronic communication may include, but are not limited to; inadvertent sending of an e-mail or text containing confidential information to the wrong recipient, theft or loss of the computer, laptop or mobile device storing confidential information, and an interception by an unauthorized third party through an unsecured network.

Agreement for Services

By writing my name below I acknoledge that I have reviewed and fully understands the terms and conditions of this agreement.