Client Agreement and Informed Consent

Please read this agreement carefully and ask me about anything that is unclear. Signing it means you understand and agree to its terms. In this agreement, "I," "me," and "my" mean Sarah Stewart, LMHC, and "you" means the client. I am licensed as a mental health counselor in Florida (LMHC), North Dakota (LPC), Idaho (LCPC), and Utah (CMHC); my license numbers are listed on my website and are available on request.

1. Services and scope

Pelorus Point provides private-pay individual psychotherapy for adults (18 and older), delivered by secure telehealth. Services include a diagnostic intake and written formulation, individual sessions, and extended sessions, as described in Section 3.
My services do not include emergency or crisis care, medication management, coaching, or forensic work such as custody evaluations, expert testimony, or disability and fitness-for-duty evaluations. If I believe a different level or type of care would serve you better, I will tell you and help you find it.

2. What to expect from therapy

Therapy can reduce distress, improve relationships, and clarify goals. It can also involve discussing painful experiences and may bring up strong emotions, and changes you make in therapy can affect your relationships, work, and decisions. I cannot guarantee any particular outcome. Progress depends in part on your active participation, including work between sessions.
We will agree on goals at the start of treatment and revisit them as we go. You may ask questions about my approach at any time, and you may change your goals or end treatment whenever you choose.
If a diagnosis is clinically needed, I will discuss it with you. Diagnoses are recorded in my clinical record. Because I do not bill insurance, they are not submitted to any insurer or other payer.

3. Services and fees

The 16 sessions in the six-month container are to be used within six months of your start date. Unused sessions expire at the end of that period unless I agree in writing to extend it. Fees for a package you have already purchased do not change during its term. For session-by-session clients, I will give at least 30 days' written notice of any fee change.

4. Payment

Container: pay $10,000 in full, or in six monthly payments by card on file (five of $1,666.67 and a final payment of $1,666.65). Your first payment holds your start date.
Intensive and extended sessions: the full fee is due to confirm the booking.

Individual sessions: payment is due at the time of each session by card on file.
Failed payments: if a payment does not go through, I will contact you. If it is not resolved within seven days, I may pause scheduling until it is.

Card details are collected and stored by a secure payment processor, not in your clinical record.

No insurance. I do not bill insurance, submit claims, or provide superbills or diagnostic codes for reimbursement. I can provide a receipt on request showing dates of service and amounts paid; receipts do not include diagnoses or clinical information.

If someone else pays. A partner or other person may pay your fee, but you remain the client. They will receive payment receipts only and will not receive clinical information unless you authorize it in writing.

Good Faith Estimate. Because you are paying without insurance, you have the right to receive a written Good Faith Estimate of expected charges. I will provide one within one business day of scheduling your intake, or within three business days of any request. If a bill is substantially higher than your estimate, you have the right to dispute it; information is available at cms.gov/nosurprises.

5. Cancellations, refunds, and ending early

Session cancellations. Please give at least 48 hours' notice to cancel or reschedule a session, and at least seven days' notice for an intensive or extended session. Late cancellations and missed sessions are billed at the full fee, and in the container they count as sessions held. I may waive the fee for a genuine emergency or illness at my discretion. If I cancel, I will reschedule at no cost to you.

Intensive and extended sessions. If you cancel with at least seven days' notice, I will reschedule or refund the fee. If you cancel with less notice, the fee is retained unless I agree to reschedule.

Ending the container early. If you end the container before it is complete, I will refund prepaid fees minus the intake ($750) and any sessions already held ($500 each). If you are on the payment plan and the value of services already delivered is more than you have paid, you owe the difference; otherwise, remaining payments stop. Refunds are issued to the original payment method within 30 days.

If I end treatment. If I end treatment or am unable to continue, prepaid fees for services not delivered will be refunded.

6. Communication between sessions

Container clients may contact me through my secure client portal. I respond within one business day (Monday to Friday, Central time). The portal is not monitored evenings, weekends, or holidays, and it is not for emergencies. Session-by-session clients do not have between-session clinical contact.
For scheduling and administrative matters you may use email or phone. Please do not send clinical information by regular email, text, or the website contact form, as these are not secure. Voicemail may not be private.

7. Emergencies

I do not provide crisis or after-hours coverage. If you are in crisis or believe you are in danger, call or text 988, call 911, or go to the nearest emergency department. At the start of treatment we will write a plan for after-hours risk. I will tell you in advance when I am unavailable.
By providing an emergency contact on the information form, you authorize me to contact that person, and to contact emergency services, if I believe you are at imminent risk of serious harm.

8. Telehealth

All sessions are held by secure video. By signing, you consent to receive psychotherapy by telehealth. You agree to:

Be physically located in Florida, Idaho, Utah, or North Dakota at the start and throughout every session, and tell me where you are at the start of each session. Please tell me in advance if you will be traveling, because I may not be able to hold a session if you are elsewhere.
Join from a private space, not while driving, and tell me if anyone else is present.
Not record any session. I will not record sessions without your written permission.

Technology can fail, and no electronic system is completely secure despite reasonable safeguards. If video drops, I will call you at the phone number on file to continue or reschedule. Telehealth may not be appropriate for every situation, and if I believe it is not appropriate for you, I will help you find other care.

9. Confidentiality and its limits

What you tell me is confidential and will not be shared without your written permission, with these exceptions:

Serious risk. If I believe you are at imminent risk of seriously harming yourself or another person, I may take steps to protect safety, including contacting emergency services, family, or others.
Abuse or neglect. I am required to report suspected abuse or neglect of a child, an older adult, or a vulnerable adult.
Legal requirements. A court order, subpoena, or licensing board investigation may require disclosure. I will assert your privilege where I can and disclose only what is required.
Consultation. I may consult with other clinicians about your care, without identifying you where possible.
Service providers. The vendors I use for records, payments, and the client portal may handle limited information under privacy obligations.
Your written authorization. For example, to coordinate care with another provider (Section 12).

The law of the state where you are located during sessions may affect these limits.

10. Sessions that include another person

If we agree that a session should include a partner, family member, colleague, or other person, you remain my only client. That person is not my client and I will not provide them treatment. Before a joint session I will agree with you on what will be discussed, and I will ask the other person to acknowledge these ground rules in writing. What you tell me privately remains confidential under Section 9. What is said in a joint session is heard by everyone present, and I cannot control what others do with it afterward.

11. Records and privacy

I keep a clinical record of your care and handle it in line with applicable privacy laws, including HIPAA where it applies, and the standards of my licensing boards. You may request access to your records as the law allows. Records are kept for the period required by the laws and boards that govern my practice and then securely destroyed.

12. Coordinating with other providers

When it serves your treatment, and only with your written consent, I will coordinate with a psychiatrist, physician, or other professional on your care team. You may withdraw that consent in writing at any time.

13. Ending treatment

You may end treatment at any time; I encourage a final session. I may end treatment if payment is not resolved, if you are not attending, if treatment is not helping or a different level of care is needed, or if I cannot continue for another professional reason. I will give you referrals when I do. If I have had no contact from you for 30 days, I may close your file after written notice.

14. Professional boundaries and online reviews

Our relationship is professional and limited to therapy. I do not accept social media connections from clients. I do not ask clients for online reviews or testimonials. If you choose to post about your experience, I cannot respond in any way that confirms you are my client. If we meet in public, I will not acknowledge you first unless you do.

15. The complimentary conversation

The free 20-minute conversation is to determine fit. It is not treatment and does not create a therapy relationship. Please do not share detailed clinical history on that call.

16. Questions, concerns, and governing law

If you have concerns about your care, I hope you will raise them with me first. You also have the right to contact the counseling licensing board in the state where you are located. This agreement is governed by the laws of [state where your practice is based], except where the law of the state where you are located requires otherwise.

17. Changes and severability

Changes to this agreement must be in writing. If any part is found unenforceable, the rest stays in effect. Nothing in this agreement limits rights you have under state or federal law.

Acknowledgment

The formal Client Agreement and signature documents will be provided separately to clients before treatment begins.