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Terms and Policy

Consent & Limits of Confidentiality/Therapy Cancellation Policy
This is to certify that I, give permission to Martha Leesman, MS, LPC, BCPC to provide behavioral health services for myself and/or child(ren), or for an adult child for whom I am legal guardian.

I have reviewed the Psychotherapist/Counselor-Client Service Agreement and the specific
assessment and/or treatment procedures have been explained to me.

The specific treatment has been described in the written Agreement and/or explained by the
clinician. If applicable, alternatives to treatment have been explained to me. Because of the
complex nature of psychotherapy and other behavioral health services, including discussing past
and present emotional pain and the stresses in life, it is quite common for persons entering this
type of treatment to have periods of time when they experience their feelings as more intense,
and perceive their condition as possibly worse. This should be discussed, and is usually

The issues of confidentiality have been reviewed, and I have been assured that all
communication between a professional and a client are held in strict confidence. However, I also
understand that there are exceptions to those laws and regulations. I understand it is the
clinician's legal responsibility to disclose certain issues for my protection and that of others, and these situations have been clarified to me. Every reasonable effort will be made to resolve issues through discussion and planning within the clinical setting, and I will be notified of any anticipated compromise of the client-therapist relationship.

I have the right to terminate the therapeutic relationship at any time that I desire, without fault,
and I have the right to seek and obtain a second opinion on the procedures and/or treatment

I understand that I am fully financially responsible for my treatment provided by the clinician, and
for any balance that is not covered by my insurance company. A billing service may be used for
the collection of insurance reimbursement and co-pay fees. Psychotherapists have the right to
seek the services of a collection agency to obtain payment of past due balances.

My signature certifies that I have received, read and understand all the information provided by
Martha Leesman, MS, LPC, BCPC about HIPAA, the clinician, the treatment to be
provided, and the expense to be incurred. I hereby give my consent for treatment. A copy of this
authorization shall be considered valid. I understand that I will be informed of any changes
considered in this document and my consent will be obtained to any changes to this agreement.

You are assured that the services will be provided in a professional manner, consistent with the
rules and regulations of all licensure boards in which Martha Leesman, MS, LPC, BCPC is
licensed/certified. Please note that it is impossible to guarantee any specific results regarding
psychotherapeutic and counseling treatment. However, every effort will be made to achieve the
best possible results for you. Maximum benefits will occur with regular attendance and your
investment in the process.

In addition to the specific treatment modality, the goals of treatment will
be regularly reviewed and up-dated between your mental health provider and you.
( Type Full Name )
Psychotherapy and Counseling Services Agreement

Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment an\d health care operations. The Notice, which is included throughout this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end o this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.


Martha L. Leesman is licensed in the state of Texas as a Licensed Professional Counselor (LPC), nationally as a National Certified Counselor (NCC) and is APA Board Certified in Professional Counseling (BCPC).

Martha L. Leesman has a Master of Science degree in Counseling Psychology from Our Lady of the Lake University in 1995. She has been in her independent private practice since 1998.


Psychotherapy and related counseling services is not easily described in general statements. It varies depending on the personalities of the clinician and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy and counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for our work together to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy and counseling can have benefits and risks. Since therapy and counseling can involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, these services have also been shown to have many benefits. These services often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and treatment plan to follow, if you decide to continue with our work together. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy and counseling can involve a large commitment of time, money, and energy, so you should be very careful about the clinician you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.


I normally conduct an evaluation that will last from 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy/counseling is begun, I will usually schedule a 45-55 minute session per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment time is scheduled, you will be expected to pay the full fee unless you provide 24 hours advance notice of cancellation. You will be required to keep a valid credit card on file to pay appointment fees, late cancellation fees and no show fees. It is important to note that insurance companies do not provide reimbursement for cancelled sessions.


My hourly fee for psychotherapy is $250 for our initial meeting and $180 for each hour session for individual therapy and $225 for each hour session for couples/family therapy. Additional services for which there is a fee could include: report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. (Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance of any legal proceedings.)


Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office between 10 AM and 6 PM, I will not be interrupted when I am with a client. When I am unavailable, please leave a message in my voice mail box at 210-606-6861 or email me at After hours, please contact 911, go to the nearest emergency room or contact your family doctor. 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 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 or the nearest emergency room and ask for the psychologist (psychiatrist) on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.


The law protects the privacy of all communications between a client and mental health provider. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record.
You should be aware that I practice with other mental health professionals and that I contract with administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such a scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All contracted support staff have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission.
If a client seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the client to the client or others, or there is a probability of immediate mental or emotional injury to the client.

There are some situations where I am permitted or required to disclose information without either your consent or Authorization.

1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the mental health provider-client privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
2. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
3. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
4. If a client files a workers compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization, for which compensation is being sought.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client's treatment. These situations are unusual in my practice.

1. If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat or harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, I may be required to provide additional information.
2. If I determine that there is a probability that the client will inflict imminent physical injury on another, or that the client will inflict imminent physical, mental or emotional harm upon him/herself, or others, I may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the client.

If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

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 now or in the future. The lows governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.


The law and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. (I am sometimes willing to conduct this review meeting without charge). If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request.

You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing.

In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that release would be harmful to your physical, mental or emotional health.


HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of Protected Health Information. These rights include requesting that I amend your record, requesting restrictions on what information from you Clinical Record is disclosed to others; requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement.


For clients under 18 years of age who are not emancipated, their parents should be aware that the law may allow parents to examine their child's treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children between 16 and 18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from the client and his/her parents that the parents consent to give up their access to their child's records. If they agree, during treatment, I will provide them only with general information about the progress of the child's treatment, and his/her attendance as =scheduled sessions. I will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.


You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.)

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due. (If such legal action is necessary, the costs will be included in the claim.)

Use of credit cards as a payment method is subject to a transaction fee (please ask for the current fee).


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will often provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Also, many times it will not be known the exact amount of your co pay or coinsurance until the Explanation of Benefits is received from your insurance company. At that time, you may be charged for an additional portion due, which will be noted on your invoice from me.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits enc. (Some managed-care plans will not allow me to provide services to you once your benefits, end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.)

You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contact).

Please keep this document for your records. Your signature on the attached Consent to Treatment form is a confirmation of being provided a copy of this document and that you have reviewed it.

If you believe your privacy rights have been violated, you may file a complaint with me personally or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing, and all complaints shall be investigated without repercussion to you. You will not be penalized for filing a complaint.

For more information about HIPAA:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free - (877) 696-6775
( Type Full Name )