SOLEO Wellness Psychotherapy Services Agreement

At SOLEO, psychotherapy is a collaborative process grounded in compassion, clinical integrity, and respect for your autonomy. Therapy can be meaningful and supportive, and may also involve exploring difficult emotions. Your honesty, feedback, and questions are essential in helping us support your goals.

All clinicians at SOLEO practice with a warm, empathic, and evidence-based approach. If at any point you feel the therapeutic fit is not meeting your needs, we welcome open conversation to explore adjustments or referrals.

Session Structure

• Sessions are typically 45–50 minutes
• Appointments will be scheduled in advance
• Session length may vary based on clinical needs, insurance requirements, or scheduling considerations

Payment for Services

• I understand that payment is due at the time of each session unless otherwise agreed
• I authorize payment of mental health benefits to SOLEO (if applicable)

Cancellation & Missed Appointment Policy

• 24 hours notice is required to cancel or reschedule
• Late cancellations or missed appointments will be charged:
  • Individual: $200 (or sliding scale payment as agreed upon with SOLEO)
  • Family: $225 (or agreed rate)
• Insurance does not cover missed appointment fees

Additional Professional Services

Services outside of sessions may include:

• Reports or letters
• Extended communication
• Coordination with other providers

Fees:

• $200/hour (prorated)
• Legal involvement: $300/hour

I understand and agree to these additional service fees

Outstanding Balances

I understand that balances over 60 days may be sent to collections or pursued legally

Insurance & Out-of-Network Policy

SOLEO is an out-of-network provider.

• Payment is due at time of service
• Superbills may be provided for reimbursement
• SOLEO does not communicate with insurance companies

I understand that reimbursement is not guaranteed

I am responsible for all fees not covered by insurance

Release of Information for Insurance

Insurance companies may request clinical information including:

• Diagnosis
• Treatment plans
• Progress summaries

I understand that submitting claims may require release of clinical information

Telehealth Services

I consent to receive telehealth services when appropriate

I understand:

• Telehealth uses electronic communication
• Technology may have limitations or risks
• I must be located in a state where my clinician is licensed
• Telehealth is not appropriate for emergencies

I agree to participate from a private location

I will not record sessions without consent

Emergency & Safety Acknowledgment

I understand telehealth is not for emergencies

If in crisis, I will:

• Call 911
• Go to nearest emergency room
• Contact crisis services

Confidentiality & Its Limits

Confidentiality applies except when required by law:

• Risk of harm to self or others
• Abuse/neglect reporting
• Court orders

I understand the limits of confidentiality

Communication & Availability

• Calls returned within ~24 business hours
• Not available for emergencies

I understand email/text is not secure or for urgent communication

Electronic Health Records

I understand my records are stored in a secure electronic system

Therapeutic vs Legal Roles

I understand clinicians do not provide forensic or legal evaluations

Termination of Therapy

Therapy may end when:

• Goals are met
• A different level of care is needed
• Logistics or clinical needs change

I understand therapy may be terminated or transitioned appropriately

HIPAA Acknowledgement*

I have received and reviewed Notice of Privacy Practices

I request a hard copy

I decline a hard copy