Policies and Procedures Form

Welcome to the practice of Tracy Deagan and Associates Psychotherapy and Violet Crown Counseling. Please read the important information below about your rights as a client and our policies.


1. All information about you is kept strictly confidential. Federal, State and / or local law or professional and ethical guidelines mandate these exceptions to your confidentiality:

A. If your counselor believes your life or someone else’s is in danger.

B. If your counselor believes a child, handicapped, and / or elderly person is being abused or neglected or is in danger of being abused or neglected. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State or Federal Law to appropriate state or local authorities. This may include “historical abuse” to these groups, please ask your therapist for more information as needed.

C. If your records are court ordered.

D. If you give written consent for your records or case information to be released.

E. If you inform us of sexual abuse by a counselor or therapist, we are required to report that individual to their licensing board.

In any of these instances, your therapist may be required to violate your confidentiality and share private information to keep you, or someone in a protected group safe.

2. We do not file insurance for clients; however, we will give you billing information to present for reimbursement. If you wish us to provide more information to your insurance company to assist with your filing we will do so only with your consent and the knowledge that this may require the release of confidential information - as will be detailed in a “Release of Information” form regarding this type of information sharing.

3. Tracy Deagan LPC-S, LCSW -S provides all practice supervision. As a supervisor and as a clinician, Ms. Deagan is responsible to the Texas State Board of Social Work Examiners who may be reached at (800) 232-3162 and / or the Texas State Board of Licensed Professional Counselors at (512) 834-6658.

Concerns, Complaints, Compliments and Your Rights

You have the right as a client to:

A. Be informed of practice’s rules and policies before participation.

B. Be informed of other appropriate services.

C. Accept or refuse services after being informed of services and policies.

D. Participate in the development of service goals.

E. Have confidentiality maintained about any and all information except as outlined above.

F. Make a complaint or compliment about services at any time to my counselor and / or the appropriate state licensing board: Texas State Board of Social Work Examiners at (800) 232-3162 or Texas State Board of Licensed Professional Counselors at (512) 834-6658.

Counseling Fees

A. Payment is expected at every session unless prior arrangements for later payment have been made with your therapist and TDA.

B. The counselor’s standard fee is $150 per session. Your fee for service is

$ ________. Checks can be made out to Tracy Deagan and Associates or TDA. Credit cards, paypal, and cash are also accepted.

Any appointment not canceled with 24 hours notice will be charged at the regular session rate.

Failure to pay fees can lead to suspension or termination of services, with appropriate referrals. Failure to pay fees and to contact this office about a payment schedule can also result in use of a third party collector.

E. We do not bill your insurance company and await reimbursement. We will bill you to assist you with reimbursement as outlined in the confidentiality section. This clause does not apply to insurance companies your therapist is a preferred provider for.

Couples Services

A. Clients attending counseling as part of a couple will have the record of these sessions noted in a joint client record. By signing below couples are asserting that they understand and agree to records being kept jointly.

B. Both individuals in these meetings must sign a “Release of Information” form in order to have information on these joint sessions released to anyone. Information on individual services to either part of a couple - or disclosures required by State or Federal Law - are not affected by this policy.


By my signature below I am agreeing to email or skype or text communication as negotiated with my therapist. I understand that VCC or TDA can not control the safety of these mediums and if I choose to use them I am agreeing to hold harmless VCC / TDA and any and all of their staff or therapists from any problem or fault ensuing from this type of contact including sharing of this material by any medium.

If you do not wish this type of contact you must clearly mark this in the subject line and body of your email and / or on the Client Information form so we know you do not want contact through this medium. Please then add a contact area so we can address you through another medium.

The contents of this form have been explained to me and with my signature I affirm I have read the information, and understand and agree to any statements or requests made to me in these policies.

Client _______________________________________ Date

(print name)

Client ______________________________________ Date


Witness _____________________________________ Date