The following is intended to familiarize you with your psychotherapist Clarillette Heredia,  LFMT

Please Read it Carefully

1. You have the right to confidentiality. This means that what you say during the session will not be  discussed outside of the session unless you give your written permission. Exceptions to  confidentiality includes issues of abuse, neglect, or plans to harm self or others, and/or upon a  received request governed by other Florida Statutes or a court order.  
2. Payment for services is due at time of service. You are responsible for co-pay and any amount that  your insurance or EAP will not cover due to date, or lack of authorization.  
3. A session consists of 45minutes (EAP) and 50 minutes (insurance) according to insurance agreement.  Private Pay sessions are 60 minutes.  
4. A 24-hour notice is required to cancel without being charged a cancelation fee. 
5. Abuse of legal or use of illegal substances during treatment is unacceptable.  
6. Please understand that initially your symptoms may worsen while in treatment, therapy is designed  to assist you with coping with these symptoms and/or stressors.  
7. Please feel free to discuss any problems or questions that may arise with your therapist. 
8. For after hour’s emergencies, you may call the Crisis Center at 234-1234 or 911. 
 
I hereby authorize Clarillette Heredia, LMFT of Solutions Corner LLC to administer therapy as deemed appropriate. I have  read and understand the above information regarding my participation in services provided by the therapist and  I agree to abide by the rules as listed above.