Treatment Agreement

11 West 33rd St., Erie, PA 16508

Please print page and mail the filled out form to the above address.

Treatment with Michelle Domowicz, M.A. may include: evaluation, therapy, case management, and/or referral to another clinician or treatment facility. I understand that the initial evaluation is $120.00, subsequent therapy sessions are $85.00/hr. and testing is $100.00/hr. I will bill only the insurance companies for which I am a provider.

Cancellation Policy: Missed appointments without 24 hour notice reduces time needed to offer available hours to other persons in need of and waiting for therapy. Therefore, you will be responsible for the full fee if you miss an appointment or do not cancel your appointment within 24hours. Insurance companies do not cover this cost. Please leave a message if I am not available at the time you call to cancel your appointment. I will call you back as soon as possible to reschedule.

Confidentiality: I respect the privilege of confidentiality and typically release information only upon obtaining your written permission. There are several exceptions to this rule of confidentiality which are dictated by state law. These exceptions include: information pertaining to child abuse and information indicating the intent of the client to harm his/herself or someone else. You have the right to access information from your chart which can be done in consultation with me.

Emergency Plan: I will check my voice mail on a regular basis. If there is an emergency, I will try to contact you as soon as possible. In my absence, another therapist will cover my cases for me and will contact you if needed. Erie County Crisis is also available 24 hours a day, the phone number 456-2014

I have read the above information and agree to it.

Signature:_____________________________________ Date:_______________

Witness:_______________________________________ Date:_______________

*lf client is 14 years or older, they might sign the treatment agreement.