Confidentiality, Cancellations, and Payment Policies

Confidentiality, Cancellations, and Payment Policies


Information shared with a psychologist is confidential and protected by law. I will not disclose confidential information about you without your formal consent. There are situations, however, in which I am required to break confidentiality. These include the following: if you are in danger of harming yourself or another person, are unable to care for yourself; if you state that you intend to physically injure someone; if there is suspected elder or dependent adult abuse, or child abuse or neglect; if I am court ordered to release information as part of a legal proceeding, or as otherwise required by law.


Appointments are scheduled weekly and last 50 minutes. You will be billed for sessions that you miss or cancel with less than 48 hours notice. Sessions will end 50 minutes after the scheduled appointment time, even if you arrive late.


By signing this form, I agree to pay Mary Deyo, Psy.D. the agreed upon fee of $250 for the initial intake appointment and $230 for each subsequent session of individual therapy.


I have read and understand this document and I have had my questions answered to my satisfaction. I understand the limits to confidentiality and I know that I can end therapy at any time that I wish. I accept, understand, and agree to abide by the contents and terms of this agreement and consent to participate in psychotherapy treatment.

Privacy Practices Confirmation

􏰱I also certify that I have received a copy of Mary Deyo, Psy.D.’s Notice of Privacy Practices detailing the provisions of HIPAA.