Service Agreement

Amber M. Gross LCPC, MS, RPT

Counseling Services

136 Maine Street Suite 6

Brunswick, ME 04011


Welcome to Amber Gross Counseling, LLC. I am so pleased to have the opportunity to work with you. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. These rights and responsibilities are described in the following sections.

Disclosure Statement:

I have a Masters of Science degree in Counseling obtained from the University of Southern Maine. I am a Licensed Clinical Professional Counselor (LCPC) and my license number is CC3952. I am also a Registered Play Therapist (RPT). I am trained for work with individuals including children, adolescents, and adults.

Orientation & Treatment Methods:

Many people enter into counseling to heal suffering, to increase well-being and to explore and ultimately understand and move through emotional and psychological obstacles in their lives. It is my belief that effective counseling is guided by the expertise you have about yourself and your willingness to enter into a mutually respectful and professional relationship with a counselor. I use a variety of modalities including play, cognitive behavioral and art therapy.

The process of counseling can sometimes bring up uncomfortable feelings such as sadness, anger, frustration, guilt and helplessness as well as difficulties in relationships and/or life routines as you make positive changes. On the other hand, counseling has been shown to have benefits such as reduction in feelings of distress, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. There are, however, no guarantees in what each individual will experience through counseling. Factors that contribute to the likelihood of these positive outcomes include being motivated to change, having open communication between you and your therapist, feeling respected and understood by your therapist, attending sessions regularly, and considering before each session how to best use your time.

Please initial each section where indicated and sign at the bottom.

Insurance billing:

I will bill your insurance if the company is familiar and reliable. You are asked to know the specifics of any deductible or copay. Payment of your portion of the fee is due at the time of service, at the beginning of each appointment. Initial authorization from the insurance is your responsibility. I will obtain any future authorizations as needed. If your insurance company fails to pay for reasons that are not of my doing, then you will be responsible for that payment. By initialing, you are giving me permission to bill your insurance company. ________(initial)


If you do not have insurance, the cost of services is $90 per 52 minute session, with the initial appointment costing $120. If your insurance doesn’t pay for sessions because of a deductible, you will be charged the contracted rate with that specific insurance company. ________(initial)


Appointments will ordinarily be approximately 52 minutes in duration. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24- hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the $50 cancelation fee. ________(initial)


Your counselor will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware.

1. If a client threatens to harm someone else, I am required under the law to take steps to inform the intended victim and appropriate law enforcement agencies.

2. If a client threatens to cause severe harm to themselves, I am permitted to reveal information to others if I believe it is necessary to prevent the threatened harm.

3. If a client reveals or I have reasonable suspicion that any child, elderly person, or incompetent person is being abused or neglected, the law requires that I report this to the appropriate county agency.

4. If a court of law orders me to release information, I am required to provide that specific information to the court.

5. If a client has been referred to me by a court of law for therapy or testing, the results of the treatment or tests ordered may have to be revealed to the court.

Some clients may choose to use technology in their counseling sessions and as a means of communication. This includes but is not limited to online counseling via telehealth platform, telephone, email, fax, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Your counselor will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. There are limitations to all of the above technology items. Your initials indicate you understand these limitations. _________(initial)


Please initial to show that a copy of the HIPPA policy for this office has been made available to you____(initial)

Communication with other providers/attorneys/doctors:With a signed release, I will reach out to providers/attorneys/doctors as needed and at the request of the client. In addition, there is a fee of $25 per 15 minutes that I spend communicating/coordinating with other providers via telephone, face to face, or e-mail. ___________


The practice of counseling is regulated by the Department of Professional and Finance Regulation. Complaints may be registered by contacting:

Board of Counseling Professionals Licensure

35 State House Station

Augusta, ME 04333

(207) 624.8674

Consent to Counseling Signature Page

Your signature below indicates that you have read this Agreement and agree to its terms.

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Client /Parent or guardian date

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Client /Parent or guardian date

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Clinician date