Office Policies and Procedures
Gopita Katharine Manning,
M.A.
EIN # 01-0671399
Updated March 2008
WELCOME! I am delighted to be your therapist/ spiritual mentor/Energy
Medicine practitioner/nutritionist/life coach/hypnotherapist, etc. My hope is that this document will answer
any questions you may have about my professional services.
The following are some very general guidelines to my work with you. Please
read this document carefully.
Your
weekly appointment time is yours to keep. Your fee for my services is $__________. Should
you cancel or postpone without a minimum of 24 hours notice, you will be charged the usual fee. If possible,
an alternate appointment may be scheduled at a mutually convenient day and time. The fee for canceled appointments
is due and payable at the beginning of your next scheduled appointment.
Therapy may be terminated after two consecutive cancellations.
Should you require additional sessions, or longer sessions
than the usual one- hour counseling sessions, I will do my best to schedule the time with you.
Fees
PAYMENT IS REQUIRED AT THE BEGINNING OF EACH THERAPY SESSION. That
means I require that you hand me a check in advance. The reasons for
this are numerous. Please ask. I do not generally use a sliding scale, so please inquire about fees before
we begin, so that there is no misunderstanding or disappointment. I raise my fees $5 per hour at the beginning
of each new calendar year. Please see a price list of my services, if you have any questions.
A $25 fee will be charged for any returned check.
Insurance
If you have health insurance, your visits may be partially reimbursed by your insurance company,
although I generally do not qualify as a provider. Please request a SUPERBILL from me and you may submit
the paperwork directly to your insurance company. Your insurance company requires diagnostic and treatment
information before reimbursing you. I will release information to the insurance company WITH YOUR PERMISSION
ONLY.
Confidentiality
Information disclosed in a session is confidential, except when related to physical
or sexual
Abuse of a minor or an elder, of when related to danger to the self or to others.
In the
case of family or adolescent counseling, I will share information with other family members with permission only, providing
a breach of confidentiality is not indicated for legal reasons.
Terminations
I have an ethical responsibility to continue our relationship as long as it is reasonably clear
that you are benefitting from the relationship. We will need to discuss termination if you are unwilling
to comply with my therapeutic recommendations or if you do not maintain your agreed financial payment. I
request that you schedule a minimum of six and a maximum of eight sessions with me after formally announcing a plan to stop
treatment. Termination can be a constructive and useful process and I request that you consider carefully
this request before signing this contract.
Telephone
I do not charge for calls, and encourage my clients to call me and make use of our relationship in this
way. Should calls become too numerous and lengthy, we will discuss the appropriate protocol and need for
reimbursing for this service.
My
Services
As I do not work under the strict licensure of certain
bureaus or protocols, I maintain firm boundaries and decorum, yet I do have many “dual” relationships.
It is important that my clients know this, and understand that many of my clients see me professionally in many venues
– as private clients, as students, and/or as group members. I also consider anyone who sees me a
friend. While I do my best to maintain some level of confidentiality and decorum, certain things will be
revealed in this type of pastoral type care, and it is important for new clients to realize that this may be different from
other types of psychotherapy or treatment they may have had in the past.
Furthermore, anyone who signs a disclaimer and who enlists me for Energy Work, allows me to
touch their bodies, unless they specifically state otherwise.
In Closing
My services to you may include nutritional advice, spiritual counseling,
and other advice, but I in no way intend to provide medical or psychological counseling, and my services
do not relate to, and are not offered or intended to provide these forms of treatment. My primary objectives
for you include having you receive my support in the AWAKENING OF CONSCIOUSNESS.
Hypnotherapy clients may receive clinical support for issues such as weight-loss, phobias, or the cessation of cigarette
smoking, but these are goal-oriented sessions, and my desire remains primarily to frame all sessions in the light of spiritual
counseling and spiritual awakening.
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I acknowledge
and agree with all the terms and conditions set forth in the above contract. For good and valuable consideration
received, I do hereby release and discharge “Gopita” Katharine Manning from any and all claims and demands of
whatever nature which I now have or may have in the future, relating to the counseling, advice or other services provided
by Gopita Katharine Manning.
Client Signature______________________________________________
Print Name__________________________________________________
Date________________________________________________________
Therapist______________________________________________________
Date_________________________________________________________
