Carter-Hargrove, Inc.

Professional
Service
Agreement
www.carterhargroveinc.com

This document is designed to explain a bunch of issues that often come up in the course of counseling sessions.
Please keep it for future reference. In order to practice in an ethical manner it is essential to present this
information to you in a clear and comprehensive manner. There may be far more information here than you ever
had an interest in knowing. However, this document is meant to provide you with information necessary for you to enter
fully in an informed way into the counseling process. Your understanding is IMPORTANT.
Please take the time it takes to read all of this carefully. After you do so, We would be glad to answer any
questions, hear any reactions you may have, or respond to any suggestions you may make about the matters
described below. We are also prepared to discuss possible changes in any of the arrangements that follow.

The Counseling
Journey:
You are about
to begin counseling
because you want to
make some changes
in your life. We will
attempt to help you achieve
those goals, but we cannot guarantee the outcome will be
what you want it to be. That is because the work depends
in part on your sustained commitment, flexibility, and even
sometimes your courage to face things you might prefer
not to look into at all. You might also find new knowledge
and new perspectives emerging in your sessions may
change your ideas about what you need to achieve or about
what might be beneficial for you. And finally, because
counseling work is always part art as science the process
might not move in precisely the directions you had
thought. So, you might have to deal with some feelings of
frustration or confusion as you go along the journey.
Your sessions could at times be hard for you. Change
often comes with feelings and states of mind that can be
distressing and by periods of of internal turmoil. As the
process of change goes forward. you might experience
moments of frustration, anxiety, feelings of depression,
increased self doubt, and episodes of feeling conflicted
about some issues in your life. In the end, you may come
to the end of your counseling journey and find many things
about your life you had not originally anticipated changing
might have been changed. For example, some of your
personal values and beliefs, your view of your past, the
nature of the relationships you are a part of, your career
Carter-Hargrove Inc.
924 Pyramid Way
Sparks, NV 89431
Professional Service Agreement for Carter-Hargrove, Inc. - 1
goals and/or your wishes for your future, your awareness
of spiritual dimensions in life, to mention only a few of
the possible changes that might result from your sessions.
Whatever your unique journey will be like, we will do our
best to be thoughtful and helpful companions along the
way.
Appointment Times:
We will make a reasonable effort to schedule your
appointments at times that are convenient for you. Ordinar-
ily, we would suggest that you come in a minimum of once
or twice per week. Most conditions seem to require this
form of sustained effort. However, some kinds of problems
are amenable to less regularly scheduled visits, while yet
others seem to warrant additional intensive effort. We will
help you to set up the pattern that best fits your needs, and
we will reevaluate that pattern from time to time.
During the later phases of your treatment. appoint-
ments may be scheduled less frequently.
Your sessions will usually last approximately 45-55
minutes. Some group, family, or couples sessions may be
scheduled for longer intervals. Sessions with children may
be scheduled for a shorter time period, particularly for
those children who are very young. We will be prepared to
discuss your exact visit frequency and its purposes with
you whenever you have questions or concerns about it.
Fees & Fee Payment:
The fee for any service you receive is due at the
beginning of the appointment time unless other payment
arrangements have been made in advance (e.g. monthly
payment, deferred payment, payment plan, and so forth).
We also reserve the right to alter your fees but would
discuss any such change with you.
(775) 331-5133
FAX (775) 448-6161
 If for some reason you need to carry an outstanding
balance on your account there will be a monthly service
charge of 1.5% (18% per year) added to your balance each
month.
Please note that the following charges will be set for
services other than individual psychotherapy (all those not
specifically listed below will be charged at the same rate as
will individual psychotherapy):
Group therapy shall be charged at the rate of .5 of the
individual therapy fee;
Psychological testing shall be charged at the same rate as
individual therapy;
Reports requested for transmission to other professionals,
agencies, lawyers, insurance companies, etc.- shall be charged
at a rate of .$100/hour for the time spent in their preparation;
Telephone calls that last longer than 6 minutes will he
charged for. Billing will be in increments of tenths of an hour
for the amount of time the call lasted. The billing rate will be
the same as your individual session charge for whatever
fraction of an hour might be used.
Other fees for other selected
services may be negotiated.
Insurance Coverage:
You may possess some form
of health insurance. If you have a the evenings, or on the weekends
health insurance policy and have
not already done so, please check
the details of its coverage with
your employer, insurance agent,
or other appropriate person. If
you have insurance, it will be your responsibility to keep
us informed about your coverage and/or about any changes
in it that may take place in the future.
We will make a reasonable effort to get payment from
your insurance carrier. Nevertheless, you are the one who
is responsible for the payment of the fees incurred.
Our function is to help you to collect whatever is owed
to you by your company, but you will continue to be
obligated for payment of fees whether or not your company
pays promptly, takes a long time to pay, or fails to honor
your claim at all.
There are typically three approaches taken in billing
for services you have received:
1 At each visit an insurance billing form/receipt will be
given to you for you to submit to your insurance company.
This form should contain all the information your company
will need from us. You will need to complete your company's
insurance claim form and attach the billing form you received
from us to it and forward it to your company for processing.
Please sign our billing form in both places indicated. Please
keep copies of these for future reference (e.g. tax purposes).
2 If you do not have insurance or choose not to use it for
your counseling services, you will still be given the same
Professional Service Agreement for Carter-Hargrove, Inc. - 2
billing form/receipt mentioned above in #1 for your personal
records. Please keep these for future reference (e.g. tax
purposes).
3 Some insurance companies and managed care compa-
nies require us to do the billing. In these instances you will be
responsible for your co-payment being made at the time
services are rendered.
Finally, some insurance carriers, particularly those that
announce a commitment to giving you managed care
require periodic sometimes lengthy treatment reports at
intervals ranging from every three or four visits to every
six months or so for them to be willing to continue to
reimburse for treatment costs. If you request that we
complete such periodic treatment update reports (which
typically take between 10-20 minutes to complete), than we
will charge you a flat fee of
$75.00 for doing each report.
Telephone Calls &
Charges:
Ordinarily, we do not mind
being telephoned at times other
than your scheduled appoint-
ments if you need a brief consul-
tation. We are available to you
during regular business hours, in
should you need to discuss something that cannot wait until
your next regularly scheduled appointment. However, we
reserve the right to charge you a fee proportionate to your
regular per session fees for telephone calls that last longer
than 6 minutes (as detailed above).
Returned Check Charges:
There is a $25.00 charge for checks that are returned
due to insufficient funds. .
Canceled & Missed Appointments:
In agreeing to see you, we are reserving a
block of time and setting that time aside just for
you. So, this time becomes a time we cannot
make available for any other purpose without
sufficient notice. In addition, unlike various
medical specialties where the appointments are
for much shorter duration (e.g. 12 minutes) and
appointment schedules are regularly over
booked in order to account for cancellations
and no shows, counseling requires reserving longer
blocks of time and does not allow for over booking. With
this in mind, we require a one week notice prior to a
cancellation in order to make other use of the time. If you
give us a weeks notice of your intention not to use one of
your appointments, we will not charge you for the time.
With such notice, we can make alternative plans. But if
you fail to provide the notice, regardless of the reason for
the absence, then you will be charged for the lost time at
the usual rate. Insurance carriers do not reimburse for
missed appointments.
We do understand, that emergencies can arise that may
prevent you from keeping your appointment(s). If this
should happen you are welcome to schedule a make-up
session in addition to your regularly scheduled
appointment(s) if time is available in our schedule. It will
be your responsibility to pursue such make-up sessions by
asking about scheduling them.
Vacations &
On-Call:
It is likely that
either you or us
will take
vacations from
our counseling
work from time
to time. Please
feel free to schedule vacations
for yourself as needed, provided only that you honor our
need to have at least a one week notice of any intended
cancellations. Of course. we would appreciate as much
advance notice of a planned vacation as you are able to
give us so that We can make some alternative use of the
time you will not be needing. For our part, We will try to
let you know several weeks ahead of any vacation sched-
ules we plan.
When we are out of the office, we continue to monitor
our voice mail each day. However, it is not customary for
us to return calls while on vacation. A vacation by its very
nature is to be time away from the demands of work for
rest and refreshment. Because of this we will leave the
name and telephone number of a qualified professional
person whose judgment we trust for you to contact in case
an emergency arises in our absence.
Confidentiality and
Privileged
Communication
and Their LIMITS:
The code of ethics of
the American Psychologi-
cal Association and
various laws of the State
of Nevada all insure that the conversations you will be
having with us will be held by us in the strictest confi-
dence. Matters you share in the context of your counseling
or therapy sessions will not be disclosed to anyone without
your express permission given in writing. However, there
are certain exceptions to this important rule that we believe
Professional Service Agreement for Carter-Hargrove, Inc. - 3
you ought to know about because one or the other of the
exceptions might come to concern you at some point in
time:
If you file an insurance claim (see Insurance Claims
above) and seek reimbursement from your insurance company
for some portion of the costs of your treatment, then you will
be giving your insurance carrier the right to inquire about you.
We may be asked by clerical or professional staff employed
by your insurance company for details about your sessions
and, unless we answer fully, you may be denied further
benefits (unfortunately even if we answer fully you may still
be denied further benefits if the company decides you do not
meet their criteria for continued treatment). Managed care
companies tend to engage in these practices every few ses-
sions. And if the insurance company personnel are not satis-
fied with the reports they receive, we may be asked to discuss
your treatment in even more detail. For example, we may be
directed to turn over all notes we have made about the entire
contents of any or all of your sessions for review. You would
then be faced with a further decision about instructing us to
comply or face the termination of your insurance benefit.
We reserve the right to seek consultation from some other
qualified professional if we believe that some additional
expertise would be helpful in rendering the best possible
service to you.
The child abuse reporting laws of the State of Nevada
require that we report even suspected cases of child abuse to
either the police or to the Child Protective Division of the
Department of Public Social Services. Child abuse includes
not only overly harsh attacks and physical punishment of
children but sexual molestation, neglect and abandonment as
well. The rule of thumb used in determining whether to
report or not is whether any reasonable person given similar
information would suspect abuse. If we decide a reasonable
person would suspect it then it becomes our obligation to
report.
There are now elder abuse and spousal abuse reporting
laws in this state as well. If we suspect that you are engaged
in administering such physical or emotional abuse. We have a
reporting obligation similar to those that constrain us in
matters of child abuse.
If you enter into a legal or administrative proceeding in
which you raise the issue of your mental status (e.g. a work-
ers compensation claim, a sanity hearing, raising mental
distress as a result of an accident or injury, or defending
yourself from a criminal charge by pleading insanity), then we
could be ordered by the court to break privilege and to testify
about matters heard in confidence whether or not you give
permission for us to testify.
Court decisions have held that we would be obligated to
attempt to warn and to protect intended victims if we were to
have reason to believe that one of my clients were likely to
inflict bodily harm on someone. Therefore, we may violate the
confidentiality of our relationship with you if we feel you are
about to hurt someone.
 We will feel a professional obligation to intervene if we
believe that you may be in imminent danger of harming your
self. In such a case, we might call one of your relatives or
friends, we could make a referral for medication for you,
and/or we might summon a psychiatric emergency team or the
police to take you to an acute care facility where you may be
held for observation and evaluation.
If you enter therapy for the purposes of seeking aid in the
commission of a felony we may be ordered by a court to give
testimony about the matter should you commit the felony and
be brought to trial.
If you bring a malpractice action against us, we will be
permitted by the courts to reveal facts about your treatment.
There are still other occasions in which your right to
confidentiality may come into question (e.g. competency
hearings. probate of your will. etc.), but these are extremely
rare. We will be happy to discuss such matters with you in the
unlikely event that any of them might arise while you are
working with us.
Confidentiality
of Sessions
With Minors:
The vast
majority of the
minors we see are
brought voluntarily by their parents and come with their
parents knowledge and blessing. Parents are understand- with you in those same therapy sessions.
ably curious about the treatment of their children. It is our
position that even young children need to develop trust in
their counselor and need some degree of privacy to do this.
With this in mind, we ask that parents of minors we am
treating respect this principle. It is very important to the
work with these little people in an atmosphere that builds
trust, openness, and honesty. It is impossible to do this if
the child believes we are a parental spy informing the
parents of everything that is said in sessions.
If you have secured our services for the treatment of
one of your minor children then we specifically request that
you contain your desire to inquire about the details of their
treatment. We need you to know that we will, indeed, bring
to your attention matters our professional sense indicates
to us are important for you to know, and we request that
you trust our judgment about this important matter. At
other times, we may have to turn your curiosity aside so
that we might provide your children with an important
sanctuary they need. We also hope you will not ask your
child(ren) what has transpired in counseling or diagnostic
sessions. In these ways we will strive to help you in your
efforts to raise you children. It is highly likely that while
treating your child(ren) there will also be family sessions
during which the progress or lack of progress in the
therapeutic work can be openly discussed with your
child(ren) or reviewed in their absence within certain
privacy limits the child(ren) needs in order to continue
Professional Service Agreement for Carter-Hargrove, Inc. - 4
their work.
Of course, if your child(ren) is/are over 18. We cannot
discuss with you anything about their work with us without
the express permission of the person(s) in question.
Confidentiality In
Marital, Family, or
Group Sessions:
Laws of the State of
Nevada extend protection
of the privacy of counsel-
ing sessions to those kinds
of services where several
persons are present at the
same time. For example, if you are in marital, family, or
group counseling sessions the other persons present cannot
he compelled to testify about matters they might have
heard discussed by you as a part of the treatment should
you find yourself in a court of law.
However, we also believe that it is important for
persons who seek help to be protected not only from the
harmful effects of disclosures of confidences in court but
from any possible fear of the potentially painful conse-
quences of gossip. Therefore, if you enter into couples,
family, or group therapy, we must insist that you not
discuss the contents of those sessions with any other
person who is not a fellow client also undergoing treatment
Termination of Counseling:
We believe that how long you remain in counseling is
a matter best left in your hands. If you want our input on
this matter, we will certainly provide it for you. Yet it must
be you who makes the ultimate decision about continuing
or ending. Our work together in your counseling is a
resource for your use; it is your right to feel free to end the
use of that resource whenever your own wisdom suggests
that termination is in your best interest. Since the therapy
relationship occupies a position of some importance to us
as well as to you, however, we hope that the decision to
end therapy will be discussed candidly and thoroughly with
us in advance of that decision. The process of ending
counseling often can proceed in the most growth enhancing
fashion when it can he fully discussed and a sense of
closure achieved. It is also helpful to know that even after
formal sessions end the work you have begun will continue
for some time as you continue to consider different issues
and work and rework them within yourself.
Fees Due On Termination:
It may be that you will have some outstanding debt at
the time you end your visits with us. If you do, we will ask
you to make a plan with us about how you will retire the
debt. We would expect you to make a commitment to send
in regular monthly payments on the balance due, and we,
will be very willing to negotiate a payment schedule with
you that would represent a mutual agreement about a level
of regular monthly payments that would be within your
means. If, however, you should leave owing us unpaid fees
and 1.) We cannot find you to make a plan for debt repay-
ment or 2.) You make a plan and violate it frequently, then
we reserve the right to get help to collect the balance due
us. In such, cases we will either turn your account over to a
collection agency or go directly to court ourselves to seek a
judgment against you. We will also then seek to recover
from you any reasonable legal or attorney fees we must
incur to collect the debt.
In either event, we will consider that you have waived
your right to confidentiality in at least a limited sense. That
is, we will exercise our right to inform a collection agency
or a court of law that you have been a client and that you
owe us fees you have failed to pay. Happily for all con-
cerned, this eventuality has proved to be extremely rare.
Consumer Protection:
If you are uncertain about whether the work you are
doing with us is of real benefit to you, we encourage you
to talk about your concerns with us. We also would like to
acknowledge your right to seek outside consultation from
some other professional, and we have absolutely no objec-
tion to your getting other opinions about your problems
and/or about what you are experiencing in your relation-
ship with us.
If at any time you feel that you are being harmed by
your experience with us, We would hope that you would
discuss the matter frankly in your sessions. If you are
dissatisfied with the response you receive, you have a right
to report your concerns to the Nevada State Board of
Psychological Examiners (the agency charged with regulat-
ing the practice of psychology in this state) or the Nevada
State Board of Marriage & Family Therapist Examiners.
The Nevada State Board of Psychology Examiners, 4600
Keitzke Lane, B-116, Reno, Nevada 89502; Telephone
775/688-1060
The Nevada State Board of Marriage & Family Therapist
Examiners, 9436 West Lake Mead Blvd., #11-J, Las Vegas,
NV 89134; Telephone 702/486-7388
Inspection Of Records:
Federal and state law grants you the right to review
any notes, documents, or forms kept by us that might be a
part of your treatment. If you would like access to these,
please discuss the matter with us. We will keep any such
records for seven years after you end your relationship with
us. Then we will destroy them.
We look forward to the work we are about to under-
take together. We hope you will find your experiences with
us helpful and meaningful for you. We understand that a
decision to seek professional counsel for problems in living
is always a difficult and important one and one that is
never made lightly. We will strive to use our best profes-
sional skills to aid in the search for solutions to your
concerns.
Fees:
Our usual and customary fee is $120.00 per session for
individual psychotherapy (45 minutes or $160.00 per 60
minute hour). However, we are committed to the belief
that fees charged for services ought to be adjusted in some
cases so that they might bear a reasonable relationship to
our clients abilities to pay. Because of this belief we will
establish a basic per session fee based upon our under-
standing of your overall financial situation at the beginning
of treatment.
At the time your fee is being set please feel free to
discuss any of these matters with us.

In connection with the treatment program or consultation in which I/we am/are participating with James A. and/or Anne E.
Carter-Hargrove, Ph.D. We acknowledge reviewing the above document and discussing this matter with him/her. In addition,
We explicitly hereby consent to the following:
Circle One
1. Yes No Release of information concerning me and/or my family to other health professionals as necessary to provide
health services to me/us, as specified above.
2. Yes No Release of information in my/our case for insurance purposes.
3. Yes No I/We acknowledge that I/we have been informed of the information contained above (pages 1-6 inclusive).
This consent is in effect only for one year from the date of out last session, unless renewed.

Signed: Date:

Signed: Date:

Professional Service Agreement for Carter-Hargrove, Inc. - 5