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Daniel Jackson, M.A., MFT Individual, Couple, Group and Family Therapy


Policy Sheet Thank you for choosing me as your counselor. I am providing this written notice of my policies and procedures to prevent any misunderstandings before we work together. Your signature below is required for verification that you received, understand, and agree to the policies and procedures outlined herein. If you have any questions at any time, please do not hesitate to ask. Hours of Practice and Fees My fee is $100 per one-hour session. Longer sessions may be arranged in advance. Payment is expected at the time of each session before our time together. Cash, personal checks and major charge cards are all acceptable. Please bring to my attention any financial hardship you may have. If my fee changes during the course of treatment, you will have at least 30 day’s notice. Once you make an appointment with me, that time is reserved for you. Therefore, cancellations with less than 24-HOUR notice, or ‘no shows’ will be charged at the full fee ($100). A $25.00 service charge will be assessed for returned checks. Contact Information The best way to reach me is by email at Alternatively, you may call -PHONE NUMBER-. Emergencies If you are in duress or have a medical/mental health emergency, go to the emergency room and/or dial 911. Crisis Services may be reached at 423-926-4171 if you are feeling suicidal and need to talk to a professional right away. When you have been stabilized please call me, or ask someone else to call on your behalf. Insurance, Medicaid and Medicare I am a fee-for-service provider (full payment is required at each session). If you wish to use mental health benefits for your sessions, you may check with your insurance provider regarding out-of-network benefits. If your particular policy has these benefits, the company may partially reimburse you once your deductible is met. I would be glad to provide a statement of your sessions, if desired. Please note that a mental health diagnosis is required. Make sure you understand your deductible, session limits and any other requirements of your policy. I am not a Medicaid or Medicare provider. Confidentiality/Duty to Warn Personal privacy is extremely important to me. Therapy services are confidential, under the terms indicated in the Privacy Notice. Some of the major conditions under which the therapist is not obligated to maintain confidentiality are: • Danger to self and others • Abuse of children or vulnerable adults In couple, parent-child, or family therapy, secrets about important information may interfere with therapy, and the therapist may encourage sharing of critical information with those who should know. In certain instances, it may be difficult to continue therapy if important information is withheld. It is your responsibility to read and make sure you understand how information obtained may or may not be used, as indicated in my Privacy Notice.


Termination Clients are free to discontinue therapy for any reason. For a successful termination, it is helpful for us to have at least two weeks to help you leave me well. About The Marriage & Family Institute (MFI) MFI consists of independent practioners who share office space. I have a private practice as a licensed legal corporation (LLC). Social Media and Electronic Communications Electronic communications cannot be guaranteed to be 100% secure. Therefore, I engage in brief email communications for scheduling only. I do not participate in lengthy electronic conversations or email therapy. By extension of the ethical guidelines that prohibit social activities between therapist and client, I do not “friend� clients or past clients on social media sites such as Facebook or LinkedIn. Benefits/risks to therapy There are no guarantees to the outcome of therapy. Benefits may include more satisfying relationships, improved mood, greater optimism, and changes in behavior. Risks may include discomfort during sessions as difficult/painful issues are discussed and processed. Negative effects are usually short term. Please share any concerns with me throughout our work together.

Informed Consent for Treatment I am entering into this therapy contract with full understanding, participation, and consent. I know I have a right to a second opinion from another mental health professional, if desired, and I have the right to terminate therapy at any time. My signature below indicates that I understand and accept the policies of Daniel Jackson and I have received a copy of this agreement. I understand his fees and know I am responsible for payment. I consent to counseling under these stated conditions.

_____________________________________________________________________ Signature Date

Receipt of Privacy Notice and Privacy Rights I have received a copy of the Privacy Notice and Privacy Rights. _____________________________________________________________________ Signature