612-419-8764 trisha@trishafalvey.com

Consent for Treatment Form

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Welcome! I am looking forward to the opportunity of working with you. As a client, you are entitled to information about the way I work.

Process: I am a Licensed Marriage and Family Therapist. The office is in a suite with other professionals but we are not connected professionally or legally. You are entitled to receive information about the methods and techniques I use, the estimated duration of our work together, confidentiality and fee structure. I will be honest and open with you and encourage you to take an active role in our work together.

Confidentiality: What you share with me personally during our sessions is confidential. However there are a few exceptions to this rule when I am obligated by law to report such as the threat or knowledge of serious harm or danger to you or others. Confidentiality guidelines may also vary as they apply to couples or adolescents and I will identify these shall they arise. Additionally all health professionals are required under federal law to comply with HIPPA regulations regarding privacy practices. On occasion I may consult with a colleague about your care so that I may benefit from their expertise. I will not use your name and will protect your identity. All consultations will be noted in your clinical record.

Fees: My fee for a 50 minute session is $120 and is prorated on the quarter hour to accommodate longer sessions or for phone calls which extend beyond 5 minutes. If you choosing to use insurance and are covered by Preferred One or MA I will file claims for you. Co-pays are due at the time of service. For all other providers, payment is due at the time of service and I will provide you with a receipt to turn in for reimbursement when applicable. I prefer payment to be written out in advance of each session to allow us to use the entire session just for you.

Cancellation policy: I have a 24 hour in advance cancellation policy. You must let me know at least 24 hours in advance of your scheduled session time in order to avoid being billed for the time I have reserved especially for you. If for any reason you should cancel after that time, you are responsible for paying the $60 cancellation fee.

Lastly and most importantly, I request that during our work together you put yourself and your commitment to this process at the top of your priority list. If you have any questions please feel free to discuss them with me.

Please complete the fields below and click the checkbox to confirm that you have read the proceeding information and that you understand your rights as a client and agree to Trisha Falvey, M.A., LMFT’s professional and financial guidelines.


I have read the proceeding information, understand my rights as a client and agree to Trisha Falvey, MA LMFT’s professional and financial guidelines.

By submitting this form with this consent box checked you are providing your electronic signature and agreeing to the terms and conditions of this form. Thank you!