PRACTICE POLICIES

APPOINTMENTS, FEES, AND CANCELLATIONS

  • Individual Session: $250

  • Couples Session: $350

    • Any individual breakout sessions conducted as a part of couples therapy are billed at the standard couples therapy rate.

  • Sliding scale fees may be offered depending on availability.

  • Accepted Insurances

    • Aetna

    • Optum plans

      • UHC, UMR, Oscar, Oxford, etc

    • New York City Employees

    • All insurances billed through Alma

    • Out of network with all other plans. I use Thrizer to help clients with submitting for out of network reimbursement. Learn more.

Cancellation Policy & Fees ($125)

The standard meeting time for psychotherapy is 50 minutes. This time is a commitment made to you and is held exclusively for you.

  • Cancellations: Cancellations must be received at least 2 full business days (48 business hours) prior to the exact start time of your scheduled appointment. Business days are considered Monday through Friday, excluding federal holidays. For example, a Monday 11:00 AM appointment must be canceled no later than the preceding Thursday at 11:00 AM. Sessions canceled with less notice will be subject to the full $125 cancellation fee (not covered by insurance).

  • Late Arrivals: If you are late for a session, we will meet for the remaining time. However, if you are more than 10 minutes late, the session will be considered a late cancellation, we will not meet, and the $125 fee will apply.

  • Rescheduling: As a courtesy, the late cancellation fee may be waived only if we are able to successfully reschedule your appointment within the same calendar week (Monday–Friday). Same-week rescheduling is strictly based on my availability and is never guaranteed. If we are unable to find a mutual time to reschedule that week, the standard $125 fee will apply.

  • Rescheduled Cancellations: If you reschedule a session and subsequently cancel that newly scheduled time, the $125 fee will be charged regardless of how much notice is given.

EXCESSIVE CANCELLATIONS AND SCHEDULING PRIVILEGES

Consistency is essential for therapeutic progress. While I understand that occasional schedule adjustments are necessary, chronic cancellations or rescheduling prevents other clients from accessing care and disrupts the clinical process.

If you cancel or reschedule your appointments excessively—defined as missing three (3) consecutive scheduled sessions, or attending less than 75% of your scheduled sessions within a two-month period—you will forfeit your recurring (standing) appointment slot.

Furthermore, in the event of a pattern of excessive cancellations or late arrivals, the therapist reserves the right to adjust your individual scheduling and cancellation requirements. These adjustments may include, but are not limited to:

  • Requiring 72 hours (3 business days) notice for cancellations instead of the standard 48 hours.

  • Requiring session fees to be paid in full at the time of booking.

  • Restricting your scheduling privileges to "same-day" or "week-to-week" availability only.

If inconsistent attendance continues despite these adjustments, it may be determined that you are not ready to engage in therapy at this time, which will result in the termination of our therapeutic relationship and the provision of referrals to other providers.

FINANCIAL RESPONSIBILITY & PAYMENT

  • Credit Card on File: All clients are required to keep a valid payment method on file through the secure client portal prior to the first session.

  • Auto-Billing: You authorize me to automatically charge your card on file for the full session fee at the time of service, as well as for any applicable late cancellation or no-show fees.

  • Outstanding Balances: If a payment method declines, you must update your billing information prior to our next scheduled appointment. If a balance remains unpaid, future sessions will be paused until the balance is resolved.

  • No Refunds: Therapy is a professional service. There are no refunds for services rendered or for late cancellation/no-show fees that have been appropriately charged.

  • Credit Card Disputes (Chargebacks): If you initiate a "chargeback" or dispute a valid charge with your bank for a session or late cancellation fee that aligns with these signed policies, I reserve the right to share necessary documentation (including this signed agreement) with the financial institution to validate the charge. Unwarranted chargebacks will result in immediate termination of treatment and the balance may be referred to collections.

TELEHEALTH & VIRTUAL SESSIONS

All telehealth sessions must be conducted in a private, stationary, and safe environment. You must be physically located in the state of [Insert Your Licensed State] during our session. Sessions cannot be conducted while you are driving, in a public space, or in a room where unauthorized individuals are present. If you log into a session in an unsuitable or unsafe environment, I will ask you to relocate. If you are unable to do so immediately, the session will be terminated and considered a late cancellation, subject to the standard $125 fee.

COMMUNICATION & ACCESSIBILITY

To ensure the highest level of privacy, please contact me through the secure Sessions Health platform or email (above) for issues between sessions. Any communications outside of session should be strictly related to scheduling or administrative needs. Clinical issues will not be processed via messaging and must be reserved for scheduled sessions. I attempt to respond to messages within 48 business hours. Messages will not be answered on weekends. If a medical or psychiatric emergency arises, please call 911, dial the 988 Suicide & Crisis Lifeline, or go to your local emergency room.

SOCIAL MEDIA & TELECOMMUNICATION

To protect your confidentiality and minimize dual relationships, I do not accept friend or contact requests from current or former clients on any personal social networking sites.

  • Professional Accounts: I maintain public, professional social media accounts and a newsletter for general psychoeducational purposes. You are not expected or required to follow or engage with my public content. If you choose to do so, you may compromise your own confidentiality by associating your profile with my practice.

  • Client Privacy & Content: The privacy of our therapeutic work is paramount. I will never share (or anonymize) your specific case, identifying information, or the private content of our sessions on my social media platforms or in my newsletters. Any public content I create focuses on general clinical themes and psychoeducation, and is never a reflection of our specific work together.

  • Engagement: I will not follow you back on any platform. I do not monitor or respond to Direct Messages (DMs) from clients on social media. All communication must occur through the secure client portal.

ADMINISTRATIVE PAPERWORK & LETTERS

Requests for clinical summaries, FMLA paperwork, workplace accommodations, or disability forms are evaluated on a strict case-by-case basis. Because these documents require a thorough clinical assessment, I do not consider paperwork requests until we have completed a minimum of 12 sessions. Meeting this minimum does not guarantee completion of the paperwork; I will only complete forms that align with my clinical assessment.

  • Emotional Support Animal (ESA) Letters: I evaluate requests for ESA letters only in select circumstances after the 12-session minimum. An ESA letter will only be considered if the animal is a clinically indicated intervention actively integrated into your ongoing treatment plan. I do not provide ESA letters solely for housing or travel accommodations.

  • Fees: Completion of approved administrative paperwork requires clinical time outside of scheduled sessions. Documentation requests will be billed at my standard hourly rate ($250/hour), prorated in 15-minute increments.

LEGAL PROCEEDINGS & COURT INVOLVEMENT

My role is to provide clinical psychotherapy, not forensic evaluations. I do not perform child custody evaluations or fitness-for-duty assessments. If you become involved in legal proceedings that require my participation (including subpoenas), you will be expected to pay for all of my professional time. My fee for preparation, travel, waiting time, and attendance at any legal proceeding is $350 per hour, payable via retainer in advance.

ILLNESS POLICY

To protect the health of all clients and staff, please do not attend in-person sessions if you are experiencing symptoms of a contagious illness. If you are mildly ill but well enough to participate, we can convert your in-person session to a secure telehealth session. If you are too ill to participate virtually, the standard cancellation policy applies.

ADMINISTRATIVE CLOSURE

Consistent attendance is vital to therapeutic progress. Should you fail to schedule or keep an appointment for three consecutive weeks, unless other arrangements have been made in advance, I must consider the professional relationship discontinued for legal and ethical reasons, and your file will be administratively closed.

Informed Consent for Therapy Services

NATURE OF THERAPY 

Psychotherapy is a collaborative process between you and your therapist aimed at addressing specific clinical goals. The therapeutic process may involve exploring difficult emotions, memories, and relational dynamics. While therapy is designed to be beneficial, there are inherent risks, including the potential to experience temporary increases in distress, anxiety, or sadness as challenging issues are processed. There are no guarantees regarding specific outcomes, but active participation and honesty are essential for clinical progress.

CONFIDENTIALITY & PRIVACY PRACTICES 

The information disclosed in psychotherapy is highly confidential and protected by state and federal law (HIPAA). I will not release information about you without your written consent, except in specific situations where I am legally and ethically mandated to do so. These exceptions include, but are not limited to:

  • Harm to Self or Others: If I assess that you pose an imminent danger to yourself or another specific, identifiable person, I am required to take protective actions, which may include contacting emergency services or the intended victim.

  • Abuse or Neglect: If I have reasonable suspicion of the abuse or neglect of a child, an elderly person, or a dependent adult, I am mandated by law to report it to the appropriate state protective agency.

  • Court Orders: If I receive a subpoena signed by a judge or a formal court order, I may be legally required to release your clinical records or testify.

MINORS 

If you are a minor, your parents or legal guardians may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential to protect the therapeutic alliance.

COUPLES THERAPY & "NO SECRETS" POLICY 

When conducting couples therapy, the "client" is the relationship itself, not the individual partners. To maintain a safe, neutral, and effective therapeutic environment, I adhere to a strict "No Secrets" policy. If you share information with me individually (via email, phone, or during an individual breakout session) that is highly relevant to the relationship or the couples therapy process, I will not keep that information a secret from your partner. My role is to assist you in disclosing this information to your partner in a clinically supportive way. If you refuse to disclose information that I deem critical to the integrity of the couples work, I may be ethically required to terminate the couples therapy.

CLINICAL TERMINATION 

Ending relationships can be difficult; therefore, it is important to have a termination process to achieve clinical closure. The appropriate length of the termination depends on the length and intensity of the treatment. I reserve the right to terminate treatment after appropriate discussion with you if I determine that psychotherapy is no longer clinically beneficial, if you require a higher level of care, or if there is a lack of compliance with treatment recommendations. If therapy is terminated for clinical reasons, I will provide you with referrals to qualified providers.


INFORMED CONSENT FOR TELEMEDICINE SERVICES

I understand that telemedicine (telehealth) is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when they are located at a different site than the provider. I hereby consent to Ana Gourley (Morgan Daffron), LMFT providing healthcare services to me via telemedicine.

By electing to participate in telemedicine, I understand and agree to the following:

1. Location and Privacy: 

I understand that I must be physically located in New York, New Jersey, Florida, Vermont, or Idaho during my sessions, as my therapist is licensed to practice within these jurisdictions. I am responsible for securing a private, stationary, and confidential space for our meetings. I understand that sessions will not be conducted if I am driving, in a public setting, or if unauthorized individuals are present, and that logging in from an unsuitable environment will result in the session being canceled and the standard late cancellation fee applied (see practice policies).

2. Confidentiality and Technology: 

I understand that the laws that protect the privacy and confidentiality of medical information also apply to telemedicine. Ana Gourley (Morgan Daffron), LMFT utilizes a HIPAA-compliant platform (Zoom with BAA signed) to provide remote psychotherapy. While all precautions are taken to ensure privacy, I understand there are inherent risks to technology, including interruptions, unauthorized access, and technical difficulties. If a technological failure occurs during a session, my therapist will attempt to contact me via phone to complete the session or reschedule.

3. Emergency Protocols: 

Because my therapist is not physically present with me, we must establish an emergency response plan. I agree to provide my exact physical location at the start of each session if it differs from my home address on file. In the event of a medical or psychiatric crisis, I understand that my therapist may be required to contact local emergency services in my immediate area.

4. Financial Responsibility: 

I attest that since I have chosen this form of communication, I have been advised that telemedicine services may or may not be covered by my specific insurance plan. I understand that I am financially responsible for any fees incurred during psychotherapy that incorporates telecommunication, including standard session fees and late cancellation fees (see practice policies for fees).

5. Clinical Appropriateness: 

I understand that telemedicine is not appropriate for all clinical presentations. Ana Gourley (Morgan Daffron), LMFT reserves the right to determine if telemedicine is a suitable modality for my specific treatment needs. If it is determined that I require a higher level of care or in-person services, my therapist will provide referrals and transition my care accordingly.

6. Revocation of Consent: 

I understand that I retain the right to withhold or withdraw my consent for telemedicine services at any time by giving written notice, without affecting my right to future care or treatment. Unless revoked in writing, this consent will remain valid for the duration of my therapeutic treatment with Ana Gourley (Morgan Daffron), LMFT.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION I understand that health information about you and your healthcare is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. It also describes your rights to the health information I keep about you, and describes certain obligations I have regarding the use and disclosure of your health information.

I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to health information.

  • Follow the terms of the notice that is currently in effect.

I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my secure client portal.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU The following categories describe different ways that I use and disclose health information.

  • For Treatment, Payment, or Health Care Operations: Federal privacy rules allow healthcare providers who have a direct treatment relationship with the client to use or disclose the client’s PHI without written authorization to carry out the provider’s own treatment, payment, or healthcare operations. For example, if I consult with another licensed healthcare provider about your condition, I am permitted to use and disclose your PHI to assist in the diagnosis and treatment of your clinical condition. Disclosures for treatment purposes are not limited to the minimum necessary standard, because providers need access to complete information to provide quality care.

  • Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, I may disclose health information in response to a court or administrative order. I may also disclose health information about you (or your minor child, if applicable) in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

  • Psychotherapy Notes: I keep “psychotherapy notes” as defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your written Authorization unless the use or disclosure is:

    • For my use in treating you.

    • For my use in training or supervising mental health practitioners.

    • For my use in defending myself in legal proceedings instituted by you.

    • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

    • Required by law, including health oversight activities or coroner duties.

    • Required to help avert a serious threat to the health and safety of others.

  • Marketing & Sale of PHI: I will never use or disclose your PHI for marketing purposes, nor will I sell your PHI.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  • When disclosure is required by state or federal law.

  • For public health activities, including mandated reporting of suspected child, elder, or dependent adult abuse, or preventing a serious threat to anyone’s health or safety.

  • For health oversight activities, including audits and investigations.

  • For judicial and administrative proceedings, including responding to a court order.

  • For law enforcement purposes, including reporting crimes occurring on my premises.

  • To coroners or medical examiners performing duties authorized by law.

  • For specialized government functions (e.g., military missions, national security).

  • For workers’ compensation purposes, to comply with workers’ compensation laws.

  • For appointment reminders and health-related benefits or services.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT

  • Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your healthcare, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

  • The Right to Request Limits: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or operations. I am not required to agree to your request, and I may say “no” if I believe it would affect your healthcare.

  • The Right to Request Restrictions for Out-of-Pocket Expenses: You have the right to request restrictions on disclosures of your PHI to health plans for payment or operations if the PHI pertains solely to a service that you have paid for out-of-pocket in full.

  • The Right to Choose How I Send PHI to You: You have the right to ask me to contact you in a specific way (e.g., a specific phone number) or to send mail to a different address. I will agree to all reasonable requests.

  • The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record. I will provide you with a copy of your record, or a summary of it, within 30 days of receiving your written request. I may charge a reasonable, cost-based fee for doing so.

  • The Right to Get a List of Disclosures: You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or operations. I will respond within 60 days. The list will include disclosures made in the last six years.

  • The Right to Correct or Update Your PHI: If you believe there is a mistake in your PHI, you have the right to request that I correct or add missing information. I may say “no” to your request, but I will tell you why in writing within 60 days.

  • The Right to a Copy of this Notice: You have the right to get a paper or electronic copy of this Notice at any time.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this form, you acknowledge that you have received and reviewed a copy of Ana Gourley (Morgan Daffron), LMFT’s HIPAA Notice of Privacy Practices.

OUT-OF-NETWORK (OON) REIMBURSEMENT & THRIZER DISCLAIMER

I utilize Thrizer, a third-party service, to help streamline the out-of-network (OON) reimbursement process for my clients. Thrizer submits claims on your behalf and may advance reimbursement funds so that you do not have to wait for your insurance company to process payments.

If you choose to utilize Thrizer, please be advised of the following policies:

  • Verification of Benefits: Reimbursement is strictly based on your specific insurance plan’s OON benefits. While Thrizer facilitates the submission process, your insurance provider dictates the final reimbursement amount. It is your sole responsibility to verify your OON benefits, deductibles, and coverage limits prior to initiating therapy.

  • Financial Responsibility: You remain responsible for my full session fee at the time of service. Thrizer does not alter the cost of psychotherapy; it is simply a tool to expedite your insurance reimbursement.

  • Claim Denials and Advanced Funds: Thrizer may advance reimbursement amounts to you based on anticipated insurance approval. If your insurance company denies or reduces a claim, Thrizer will attempt to dispute it on your behalf. However, if the insurance company ultimately refuses reimbursement, you are financially responsible for the difference and may be required to return any advanced funds to Thrizer.

  • Clinical Documentation: Insurance denials are occasionally based on the payer's internal review of clinical documentation. I maintain clinical records that meet legal and ethical standards for diagnosis and medical necessity. However, insurance companies make independent determinations regarding reimbursement, which are entirely outside of my control. I do not alter clinical diagnoses or treatment codes solely to secure insurance reimbursement.

  • Third-Party Liability: Thrizer is an independent, third-party entity. While I facilitate the use of this platform to make therapy more accessible, I am not liable for any claim denials, processing delays, platform errors, or changes in your insurance coverage.

I encourage you to contact Thrizer or your insurance provider directly with any questions regarding how your OON benefits apply to your treatment.

Credit Card Authorization

By signing below, I authorize Ana Gourley (Morgan Daffron, LMFT) to securely store my credit card, debit card, or HSA/FSA card on file through the practice’s secure, PCI-compliant third-party billing and Electronic Health Record (EHR) platforms (which may include Sessions Health, Alma, or Thrizer, depending on my specific billing arrangement).

I authorize Ana Gourley (Morgan Daffron), LMFT and the applicable billing platform to automatically charge this payment method for psychotherapy sessions and related clinical services.

I authorize charges for:

  • Full session fees at the time of service.

  • Prorated fees for approved administrative paperwork or clinical phone calls.

  • Late Cancellation or No-Show fees ($125), as explicitly defined in the Practice Policies document.

  • Any outstanding account balances.

I understand that my full payment information is tokenized and stored securely by these third-party processors, and that Ana Gourley (Morgan Daffron), LMFT does not retain my raw credit card data.

I understand that this authorization will remain in effect for the duration of my treatment. I agree to promptly update my payment information if my card expires, is lost, or is declined.

I acknowledge that initiating an unwarranted credit card dispute (chargeback) for fees that align with the signed Practice Policies may result in the immediate termination of the therapeutic relationship and the referral of my unpaid balance to a collections agency.

Finally, I authorize Ana Gourley (Morgan Daffron), LMFT and/or the utilized billing platform to send electronic receipts of payments made (via email or text message) to the contact information I have provided.

YOUR RIGHT TO A "GOOD FAITH ESTIMATE"

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

  • Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.