Bridge the gap from unease to peace.

Fees

My fee is $120, based on a 50-minute session for individuals and couples. If we arrange a longer counseling session, the hourly rate will be prorated. Fees are subject to reasonable periodic increase, not more often than once a 12-month period. I will give you 1–2 months' notice prior to making that change.

In the event of telephone counseling that extends beyond 15 minutes, the fee will be prorated based on your standard hourly rate.

Payment

Payment is expected at the time of service unless other arrangements have been made. I accept: Cash (receipt available upon request), Personal checks (made out to "Sumrah Jan" — $25 fee on 1st returned check, $35 on 2nd), and Credit Cards via Ivy Pay. ALL clients are required to have a credit card on file, which may be charged for no-shows or cancellations with less than 24 hours' notice.

Insurance Reimbursement

If you have a health insurance policy, it may provide some coverage for your treatment. You (not the insurance company) are responsible for full payment of session fees. I will provide a superbill upon request for out-of-network reimbursement.

Payment Past Due

If payment is past due for over 30 days, I may submit your name and amount owed to a collection agency or small claims court. A 3% interest rate will be applied to all balances 30+ days overdue.

Your appointment time is reserved just for you. I hold your spot and do not schedule another client in that slot until I am given notice. When you are considerate regarding cancellations, I can schedule others who are waiting for an appointment.

If you fail to cancel a scheduled appointment, I cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice, unless it is due to illness or an emergency.

Consecutive no-shows and frequent cancellations due to schedule conflicts could result in loss of assigned appointment time at my discretion (more than once a month).

No Show / Late Arrivals

If you are late by more than 15 minutes and have not contacted me (text or call), I will consider you a "no-show" and you will be charged for the appointment. Fees will be charged for the full 50 minutes even if you are late — appointments are often scheduled back-to-back.

If you are canceling or changing an appointment, please call my voicemail at (925) 338-7526.

Psychological Services

Psychotherapy can be a difficult as well as rewarding process. Since therapy often involves exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy can often lead to better relationships, solutions to specific problems, and a reduction in feelings of distress.

Confidentiality — Adults

Everything we talk about in sessions will be held confidential and privileged as protected by law. No one will know the content of our counseling sessions unless you tell them or sign a release of information. However, I am required to disclose information without consent if: a client poses a serious threat to themselves or others; child, elder, or dependent adult abuse is suspected; or a government agency or court requires it.

Confidentiality — Children & Teenagers

My first responsibility is to honor our confidential relationship. Specific information will not be shared with parents unless you give permission. Exceptions include: sexual activity under age 14, abuse, potential for suicide or homicide.

Availability

Sessions are by appointment. For phone contact between sessions, please leave a confidential voicemail at (925) 338-7526. I will make every effort to return calls within one business day. For crisis emergencies, please call 911 or the Contra Costa Crisis Line at 1-800-833-2900.

Agreement

When you sign this document, it represents an agreement between Sumrah Jan and you. By submitting this form, you acknowledge receipt of the informed consent and agree to the terms described above. It is your responsibility to read through the full consent and raise any questions or concerns with your therapist.