Online Tx Form

 Richard R. Boersma, M.S.

     810 Lincoln, P.O. Box 240, Steamboat Springs, CO 80477    Voice: 970-879-7637    Fax: 970-871- 6811

 

Online Counseling Agreement

 

I understand that:

  • my online confidentiality and privacy are assured at the psychotherapy office end, thanks to an encrypted "secure" Internet connection.  However, I am responsible for Internet security at my own end.
  • "synchronous" online sessions (when Mr. Boersma and I will be online simultaneously) must be scheduled and adhered to just as conventional office sessions require, so that both parties can rely upon a schedule; cancellations less than 24 hours in advance may be charged at half-rate.
  • "sequential" sessions (communications back and forth are not immediate) do not need to be scheduled, and will be answered within 24 hours.
  • Richard Boersma, M.S., will maintain a printed summary of our online communications in a confidential physical file in his office.
  • Mr. Boersma may not always be available to me at all hours, although he will provide phone numbers for me to use for backup contact.  Should I experience a personal emergency and be unable to reach him, I will contact emergency services (call 911).
  • the fee for synchronous online counseling is $65 for a 25 minute session and $90 for a 55 minute session. 
  • the fee for sequential (non-synchronous) online counseling is assessed by Mr. Boersma per response.  He will adjust this fee according to his record of time and effort involved; I will have the right to question any charges without risk of injuring our therapeutic relationship.
  • health insurance plans do not pay for online mental health counseling services; if I want to submit charges to my insurer, a paper billing will be provided to me to forward to my insurer.
  • I will provide credit card information when beginning online counseling, either as my way or paying or as a backup payment measure; I can pay for billed services by any method I desire: cash, check, or credit card.
  • I am under no obligation to continue online counseling (or any therapy arrangement); I can suspend or discontinue counseling at any time, but will inform Mr. Boersma of my desire as a courtesy.

 

 

 

      Client Signature                                                              Date