(Version/Effective Date: 7/22/2022)

• Initial Clinical Interview (60 minute initial intake session): $𝟮50
• Individual, Marital, and Family Therapy (per 50-60 minute session): $𝟭75
• Psychological evaluation: $𝟮500
• Per hour­— Psychological evaluation rate: $𝟮5𝟬
• Home & school visits, drive time, report writing and extensive coordination of care contacts
  are billed in 15 minute increments at $62.50 per increment.
-𝗡𝗼 𝗶𝗻𝘀𝘂𝗿𝗮𝗻𝗰𝗲 𝗮𝗰𝗰𝗲𝗽𝘁𝗲𝗱.

I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment (unless illness or emergency).  If I do not cancel at least 24 hours in advanced and do not show up, I will be charged for that appointment. I agree to pay for appointments or those where I fail to give enough notice that I will not attend. I am aware that Dr. Radtke-Rounds does not accept insurance and that it will be my responsibility to seek reimbursement from my insurer if I so desire.

During the process of treatment, I understand that at times I may feel an increase of distress. I will discuss this with Dr. Radtke-Rounds so that she may facilitate my growth. I understand that my sessions will be kept confidential.  Exceptions to confidentiality include should I be at risk to harm myself or another person and in cases of suspected child or elder abuse or neglect. I agree to disclose thoughts of hurting myself or others to Dr. Radtke-Rounds and to work with her to develop and implement a plan for my safety. Dr. Radtke-Rounds is legally and ethically obligated to breach confidentiality if I am at serious risk or harming myself or another person.