About Counseling; Together we will identify your problem, set goals for therapy and a time frame in which these goals will be
accomplished. We will discuss a diagnosis early and whether I am qualified to address your concerns. If treatment of your
problem reveals conditions that are outside my areas of expertise, it is my ethical responsibility to refer you to another
professional for treatment.

I am a humanistic therapist with strong beliefs in how biology affects personality and behavior. I practice verbal psychotherapy
that includes analysis and awareness of thought processes, bibliotherapy, conflict resolution, communication, problem solving
and often homework. You are in control of the therapy however, and can decline my recommendations at any time. Please keep
in mind that change can happen after one session, or it can take a little time. If our work together is not progressing to your
liking, either too fast or too slow, we need to discuss it.

If you do not feel that we are a good match, please let me recommend someone else. Our relationship will remain
professional at all times. I am here to be of service to your growth. You will not be paying me to be your friend, lover, mentor or
surrogate parent.

Please consult my web page www.kathyradina.com for further details about me and my philosophy of treatment.

I will not disclose information about your counseling without your written consent. Exceptions will be made if you indicate that
you may be of harm to yourself or another, or if you disclose any type of child or elder abuse. In these cases, I am obligated by
law to contact any parties involved, and/or the appropriate reporting agencies.

I keep progress notes in a private file. You may have access to this file anytime you wish, however, if you participate in couple
or family therapy, in order to respect the confidentiality of the other parties involved I will not be able to disclose the contents of
the files without everyone’s signature. If you sue for mental health injury, your mental health history (my file) may be requested
by the court. In the event of my disability or demise, my administrator will refer all my files to an associate of equal credentials for
disposition. Your records will not be released without your prior written authorization, unless they are required by court order.

As you might imagine, I may not be reached at all times. You may find yourself in the middle of a crisis after hours, or maybe
even when I am on vacation and won’t be available for several days. In the event of such an emergency, please call
VALUE OPTIONS 602-222-9444, they have 24 hour crisis counseling. Understand that I am not affiliated with this agency,
and they will know nothing about your case. They are available to help you through the crisis. Do not hesitate to call.

The Details: The fees for my services are as follows:
$90 for a 50 minute session, individual or couple
$125 for an extended couple session of 75 minutes
$50 for appointments canceled with less than 24 hour notice. (Insurance does not cover this.)
Fees are payable at the time of service. It is nice if you have your check made out in advance so we do not waste counseling
time. I cannot accept credit cards. These fees are negotiable, if they present a hardship please let me know.

The first five minutes of telephone counseling is free, after that I will bill you in 15 minute intervals payable at our next session.
I am happy to counsel you on the phone if prior arrangements have been made, but it is my sincere belief that face to face
counseling is the most effective.

My fee for filling out reports, consulting and travel time when applicable is $225 per hour with a one half hour minimum. I do
not have the qualifications to give expert court testimony, but if you insist, my fee is $300 per hour, with a one hour minimum,
plus costs for reports and travel time as per above. Time spent waiting in court will be billed as travel time.

I am happy to give you a receipt that is accepted by insurance companies for reimbursement. Please be aware that a
diagnosis ascribed for insurance purposes will be a part of that receipt. It is your responsibility to be aware of your benefits, and
all fees are your obligation.

I understand the contents of this document, and by signing below do voluntarily consent to this agreement, and grant Kathy
Radina, M. Ed., permission to provide outpatient therapy to me and/or
________________________________________________________________ (child/minor).
Signature; _________________________________________________________________ Date; ____/____/__________
Kathy Radina, M. Ed. _______________________________________________________ Date; ____/____/__________