EUGENIA E. MOORE LCSW-C

SERVICE AGREEMENT

NAME(s)_________________________________

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

Your verbal communication and clinical records are strictly confidential except for:
a) information you and/or your child(ren) report about physical or sexual abuse; then, by law, I am obligated to report this information to Child Protective Services,
b) when you sign a release to have specific information shared,
c) if you provide information that informs me that you are in danger of harming yourself or others. If an emergency arises for which the client or their guardian feels immediate attention is necessary, the client or the guardian understands they are to contact emergency services directly. Eugenia E. Moore, LCSW-C will follow-up those emergency services with standard counseling and support to the client or the client’s family.

FEES:

Clients are expected to pay at the time of service unless other arrangements have been agreed upon by both provider and client.  Fee for a 50-minute individual session is $170.00.  Fee for a 55-minute couple’s session is $185.00.  (Monthly statements can be provided for insurance provider reimbursement claims).

APPOINTMENT CANCELLATION POLICY:

Clients are expected to contact me, a minimum of 24 hours prior to cancel/or change an appointment. Failure to give 24 hours notice will result in a full fee for the cancelled session. Extenuating circumstances are considered when appropriate.

Client(s) Signature_________________________Date_________________

314 WYNDHURST AVENUE. BALTIMORE. MD. 21210. 410-967-8882