The Learning Assistance Center
Dr. Alicia Snow
823 Village Square Dr. Suite 5
Tomball, TX 77375
713-240-8609
Therapy/Testing Agreement/Privacy Policy
Welcome to the Learning Assistance Center. This form answers the questions that clients usually have when they begin therapy. It will also outline expectations for therapy and my privacy policy. Please ask any questions that you have. You will be asked to sign this document and retain a copy for your records.
Office Space:
The office building is leased by other professionals. Please be seated in the waiting room at the entrance and Dr. Snow will come to greet you for your appointment. Please understand the need to be considerate of the noise level in the waiting area.
Session Fees:
The fee for a 45 minute session is $150.00. Please make checks payable to The Learning Assistance Center or LAC.. Payment is due at the time of service. Phone calls that go beyond making and canceling appointments are billed at the same rate, which averages to $3.33 per minute. After hour and weekend calls will be billed at a rate of $5.00 per minute.
If you will be seeing Dr. Snow for testing services only, she will discuss the tests to be given and the fees that will apply. Half of the testing fee is due prior to testing and the remaining half will be due when tests results are provided.
Dr. Snow will attend school meetings upon request. These meetings are billed at the rate of $200.00 an hour.
No shows will be billed at the regular session price of $150.00.
Insurance:
I do not contract with insurance companies. You may be eligible for “out of network benefits”, but will need to research the extent of your coverage to make this determination. You are responsible for completing and filing the necessary paperwork for insurance reimbursement. I will provide you with a receipt for services rendered. Please let me know if you plan to access insurance benefits as additional information, such as specific diagnosis, is usually required. Please be aware that I have no control or responsibility for confidentiality procedures employed by your insurance company. I may be required to provide the company with sensitive personal information (i.e. personal history, current mental status, etc.) for you to be reimbursed.
Confidentiality:
All information shared in session is held in strictest confidence, according to federal regulations. The following are exceptions: 1) legal obligation, such as reporting child or elder abuse, court subpoena 2) suspected personal danger to yourself or an identifiable victim, 3) information required by insurance company for payment (for which you consented), 4) information provided to parents if the client is a minor, 5) valid collection of debt, and/or 6) consultation with other professionals in order to aid in treatment (identifying information is withheld unless consent is given). Release of information to other individuals, agencies or professionals may only be done with your written consent.
Office Hours:
Office hours are by appointment only.
Emergencies:
As a rule, my practice is not crisis oriented in nature. If you feel you will need more intensive after hours support on a regular basis, please inform me so an appropriate referral may be made.
You may call Dr. Snow at 713-240-8609 understanding that you will be billed for such calls as noted previously. In the event of a health emergency call 911 or go/be taken to the nearest emergency room.
Complaints:
Dr. Snow follows the rules of the Texas State Board of Examiners of Psychologists. Should you have a complaint you may contact the Board at 800-821-3205.
Risks/Benefits of Therapy
Dr. Snow mainly works within a Cognitive Behavioral approach to address the problems of clients. This approach involves the analysis of behaviors and thoughts that contribute to difficulties. You will likely be asked to complete homework assignments between sessions. It is critical that you make every effort to comply. Therapy can be hard work and most of the work must continue after the 45 minute consultation. Like many other things, you get out what you put in.
Sometimes things may appear to get worse when treatment begins, especially when treating children and adolescents. Children will often react negatively to attempts at changing things. Clients sometimes experience increased levels of sadness, guilt, anger, frustration, loneliness or helplessness as they begin to discuss the circumstances of their present or past.
The benefits of therapy have been scientifically researched and validated. Therapy often allows for feelings to be expressed and relieved and new skills learned that can greatly increase an individual’s ability to cope with the stressors of life and relationships. No guarantees can be made that therapy will solve immediate problems, as many factors influence treatment success including client/therapist match and client readiness for change.
Termination of Treatment:
If at any time you feel that the therapy you are receiving is not helpful or necessary, you may terminate the relationship. It is often helpful to allow 1 session for termination to be discussed. Dr. Snow reserves the right to end the therapy relationship should she feel that the treatment she is capable of offering is not in the best interest of the client. If further treatment is necessary she will provide the client with a referral of an appropriate service provider.
Agreement:
I, _____________________________, confirm that I have read, or have had read to me, in its entirety, this document. I have discussed those points I did not understand and have had my questions answered. I agree to act according to the policies and procedures listed in this document. I understand that no specific promises have been made to me by Dr. Alicia Snow or The Learning Assistance Center about the results of treatment, the effectiveness of the procedures used by her, or the number of sessions necessary for therapy to be effective. I understand that after therapy begins, I have the right to withdraw my consent at any time, for any reason. I will make every effort t discuss my concerns about my progress with Dr. Snow before making any decisions to terminate treatment.
I hereby agree to enter into therapy with Alicia Snow, Ph.D. and to cooperate fully and to the best of my ability.
______________________________ _________________
Signature of Client (Parent/Guardian) Date
Having met and discussed with this client (and/or client’s parent/guardian) the policies and procedures outlined in this document and having responded to all questions posed, I believe this person fully understands the information presented. I find no reason to believe this person is not fully competent and capable, legally or otherwise, to give informed consent for treatment. Therefore, I, Alicia Snow, Ph.D., agree to enter into a counseling relationship with this client.
_____________________________ ________________
Alicia Snow, Ph.D. Date