Gibson Counseling Terms of Business

RATES/INSURANCE: Self pay rate is $150.00 for 50 minutes and $75.00 for 20 minutes. These fees are applied for any service rendered that is not
covered by a third party payer and includes therapy sessions, phone calls, and consultations. $40.00 NSF check fee may be added to your account for
any NSF check returned by your bank. We will bill primary insurance, however you are liable for any charges not covered by insurance. I attest that I
have contacted my insurance company and understand my benefits. Insurance or other managed care companies may not cover sessions that are
conducted via teletherapy.

CREDIT CARD ON FILE: We keep credit cards on file through a secure credit card system with a $5 administration fee. We
will use this credit card for no show fees or outstanding balances. By signing this form you consent to have an active credit card on file and be charged
for no show fees and outstanding balances. If you fail to have an active credit card on file you will be unable to receive services. If a credit card declines
it is not considered an active credit card.

COMMUNICATION: We will communicate with you through the patient portal, email, text and by phone. These communications will include reminders
for appointments and communication related to billing and scheduling. The most secure way to communicate is through the patient portal and encrypted
email. If you choose to communicate through alternate means you are agreeing to non secure communication and Gibson Counseling PLLC is not
liable. No video or audio recordings are allowed, as it is prohibited and against the law without consent.

CANCELLATION: We ask that you give a minimum of 24 HOURS ADVANCE NOTICE if you must reschedule. You will be charged for a no-show or late
cancellation. The cancellation fee will be $60 for 60 min sessions and $90 for a 90 min session. If you have a credit card on file, we will use this credit
card to charge the no show fee. For teletherapy It is the clients responsibility to test their internet connection and zoom capabilities 48 hours in advance
to ensure a reliable connection and familiarity with use. If there is a loss of connection or technical difficulty by the client they will still be fully responsible
for the session.

LICENSING: All counselors are contracted by Gibson Counseling PLLC. By signing this consent you are agreeing to these terms with Gibson
Counseling PLLC and your counselor: Danielle Linders LPC# 70982 LCDC#13022, Sally Guerra LPC #13512 LCDC #5301, Sheryl Stiffler
LMFT#201022, ALy Livingston-Shelburne LPC# 72489, Amber Clemens, LMFT #203023, Kyle Dickerson LMFT # 203128, Robert Gallegos LPC-S#
71501, Paulina Pina LPC#76099, Whitney Woodby LPC#80442, Amanda Durst #66175. Dayle Malen LCSW# 65783 and Christina Glaze LCSW #

RISKS AND BENEFITS: Counseling and teletherapy are beneficial, but as with any treatment there are inherent risks. During counseling, you will
have discussions about personal issues, which may bring to the surface uncomfortable emotions. Some of the possible benefits are improved personal
relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, however, it is our goal to work
with you to attain your personal goals. Some risks of teletherapy are the transmission of my information could be disrupted or distorted by technical
failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could
be accessed by unauthorized persons.

EMERGENCY/AFTER HOURS: If there is an increase in symptoms or decrease in functioning, the client is to
contact the therapist at 512-633-7839 to set up an appointment. If it is an emergency or after hours the client is to call 911, go to the nearest emergency
room or call a 24 hour crisis line 1-800-841-1255.

COURT FEES: Clients are discouraged from having a therapist subpoenaed. It is typically not in the child’s best interest for a therapist to testify in court
proceedings, as it will impact the client/therapist relationship based on standard of care. None of our therapists specialize in court appearances, however
they can provide summary documentation or consult with the guardian ad litem. You are responsible for all court related fees, however it does not mean
that testimony will be solely in your favor as only facts and professional opinions can be given. If a therapist is subpoenaed for the client (regardless of
who the subpoena came from), the following fees apply to the client: the client is responsible for a minimum fee of $2000 per day of subpoena. In
addition, you may be assessed $250 an hour beyond the minimum, which may include, but is not limited to: preparation, consultations with lawyers or
legal representatives (including but not limited to guardian ad litem, probation officer or social workers), depositions, travel, testimony, presence in court
even if testimony is not given, filing documentation and any attorney fees incurred by the therapist. These fees will be paid 7 business days in advance
and court appearances will require a subpoena. If the court appearance is rescheduled or cancelled and the client provides a minimum of 72 hours
advanced notice, half of the fee ($1000) will be refundable, however the client will still be responsible for any fees accumulated related to preparation for

TELETHERAPY: I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and
education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental
information, both orally and visually. Teletherapy sessions are not to be recorded in any way unless agreed to in writing by mutual consent. All records
of teletherapy sessions will be maintained in the same manner as in person sessions.

CONSENT TO TREATMENT: By signing this consent form as the client or guardian of said client, I acknowledge that I have read, understand, and
agree to the terms and conditions contained in this form between myself, my therapist and Gibson Counseling, PLLC. As a guardian, I certify that I have
complied with all legal guidelines pertaining to the minor as it pertains to medical consent, this includes but is not exclusive to, notifying other guardians,
providing accurate information to Gibson Counseling regarding other guardians and ensuring consent is received from all appropriate parties. By signing
as the guardian I am stating that I have authority to consent to treatment for this minor child. I have been given appropriate opportunity to address any
questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health services from my therapist(s) at
Gibson Counseling, PLLC. in person or via teletherapy and I understand that I may stop such treatment or services at any time.



Mon By Appointment
Tue By Appointment
Wed By Appointment
Thu By Appointment
Fri By Appointment
Sat By Appointment
Sun Closed
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2201 Double Creek Drive, Unit 1003, Round Rock, TX 78664
(512) 633-7839
1101 Satellite View, Suite 402, Round Rock, TX 78665
(512) 633-7839
921 West New Hope Drive, Suite 201, Cedar Park, TX 78613
(512) 633-7839