New Client Intake

Description of Services:

The services provided are individual or couple psychotherapy sessions with Jonah Taylor, LCSW.

Per-Session Fees: Payment Schedule: The intake session fee and any one-time appointment fee are charged at the time of booking. Ongoing recurring session fees are charged on the morning of each scheduled session. A card is kept securely on file via Stripe. Cash or check may be arranged for in-person sessions.

Note: The actual number, length, and type of sessions will depend on your needs, how the work develops, and whether we are meeting individually or as a couple.

Estimated Treatment Range (required by federal law):
A typical course of therapy involves 12-24 sessions over 6-12 months, plus the initial intake. Based on the per-session fees above, the estimated total cost ranges from $2,625 to $6,825 depending on session type, length, and frequency. This estimate reflects the current fee schedule; your actual cost will depend on how often we meet and the type of sessions.

Your Rights:
You have the right to receive a Good Faith Estimate explaining how much your medical care will cost. If you receive a bill substantially higher than this estimate, you have the right to dispute it. Visit www.cms.gov/nosurprises or call 412-206-9080 for more information.

The Center for Mind & Relationship
134 S Highland Ave, Suite 310, Pittsburgh, PA 15206
Also offering online therapy in PA, NJ, NM, and RI
412-206-9080 | mindandrelationship.com
Therapist: Jonah Taylor, LCSW | NPI: 1437891546

1. Nature of Psychotherapy
Psychotherapy involves a collaborative process aimed at improving mental, emotional, and behavioral well-being. It can lead to significant personal growth but may also involve discussing uncomfortable topics and experiencing difficult emotions. There are no guarantees regarding the outcome of therapy.

2. Therapist Qualifications
Jonah Taylor is a Licensed Clinical Social Worker (LCSW) with advanced training in Sex Therapy, Psychodynamic Psychotherapy, and Emotionally Focused Therapy for couples.

3. In-Person and Online Services
Online therapy is available to clients in PA, NJ, NM, and RI. You must be physically located in one of these states during sessions.

4. Confidentiality
All information shared is confidential, with exceptions for: duty to warn/protect, child or elder abuse reporting, court orders, supervision/consultation, and insurance (superbills).

5. Appointments
Sessions are typically 53-60 minutes, with extended couples sessions available when clinically useful. 48 hours' notice is required for cancellation. Late cancellations or no-shows incur the full reserved session fee.

6. Fees
Current fees are $225 for the initial intake session, $200 for standard individual psychotherapy, $225 for standard couples therapy, and $280 for extended couples sessions. The intake and any one-time appointment fees are charged at the time of booking; ongoing recurring session fees are charged on the morning of each session, via a card kept securely on file with Stripe. I do not bill insurance directly, but I can provide a superbill for possible out-of-network reimbursement.

7. Emergencies
Call 911 for emergencies. Crisis: 988 (Suicide Prevention) or text HOME to 741741.

8. Termination
You may terminate therapy at any time. Referrals will be provided if needed.

Effective Date: June 1, 2025

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

How We Use Your PHI:
We may use your Protected Health Information for treatment, payment, and healthcare operations without prior written authorization. We may also disclose PHI as required by law, for public health activities, health oversight, judicial proceedings, law enforcement, and to prevent serious threats to health or safety.

Uses Requiring Authorization:
Psychotherapy notes, marketing, and sale of PHI require your written authorization.

Your Rights:
You have the right to request restrictions, receive confidential communications, inspect and copy your PHI, request amendments, receive an accounting of disclosures, obtain a paper copy of this notice, and be notified of any breach.

Data Security:
We use HIPAA-compliant Google Workspace with a Business Associate Agreement (BAA) for all electronic communications and records.

Our Duties:
We are required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices regarding your information, and to notify you if a breach of your unsecured protected health information occurs.

We are required to abide by the terms of the notice currently in effect. We reserve the right to change this notice, and to make the revised notice effective for all protected health information we maintain, including information created or received before the change. If we revise this notice, we will provide you with the revised notice at your next appointment, and you may request a copy at any time.

Complaints:
If you believe your privacy rights have been violated, you may complain to this practice and to the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against, penalized, or denied services for filing a complaint.

To complain to this practice: contact Jonah Taylor, LCSW at 412-206-9080 or jonah@mindandrelationship.com. Please describe what happened and when. You may complain verbally or in writing.

To complain to the federal government: file with the HHS Office for Civil Rights (OCR) online at ocrportal.hhs.gov, by email to OCRComplaint@hhs.gov, or by phone at 1-800-368-1019 (TDD 1-800-537-7697). Complaints from Pennsylvania are handled by the OCR regional office at 801 Market Street, Suite 9300, Philadelphia, PA 19107. A complaint must generally be filed within 180 days of when you knew the act occurred.

I. Financial Responsibility Agreement

Current fees are $225 for the initial intake session, $200 for standard individual psychotherapy, $225 for standard couples therapy, and $280 for extended couples sessions. This is a private-pay practice, and while I can provide you with detailed receipts ("superbills") to submit to your insurer if you have out-of-network benefits, you are responsible for payment regardless of insurance reimbursement. Learn more about out-of-network benefits and why this practice is private-pay →

II. Payment Methods
Credit/Debit Card (stored securely via Stripe), Cash (in-person only), Check (in-person only).

III. Credit/Debit Card Authorization
I authorize The Center for Mind & Relationship to securely store my card via Stripe and charge it for: (1) the intake session fee at the time of booking; (2) any subsequent one-time appointment fee at the time of booking; (3) ongoing recurring weekly or biweekly appointment fees on the morning of each scheduled session; (4) any applicable late cancellation, no-show, or late reschedule fee equal to the full reserved session fee.

IV. Cancellation, Reschedule & Credit Policy
Session fees are not refundable once paid, except as described below. The following terms apply:
• Cancellation with at least 48 hours notice (or in special circumstances such as illness, at the practice's discretion): the fee paid will be applied as a credit toward my next session. No refund is issued.
• Cancellation with less than 48 hours notice (late cancellation) or no-show: the session fee is forfeited.
• Reschedule with at least 48 hours notice: no fee. The original payment carries over to the new session date.
• Reschedule with less than 48 hours notice: no fee if the new appointment falls within the same calendar week (Monday–Sunday) as the original session. If the new appointment falls in a later week, the original payment carries over to the new session date and a late reschedule fee equal to the full session fee will be charged at the time of reschedule. This works out the same as a late cancellation followed by booking a new session — rescheduling is the better option, because you keep the appointment.
• If the practice cancels a session, the payment carries forward as a credit toward my next session, or is refunded to me, whichever I prefer.
• Credits carry forward with no expiration date. If I end therapy while holding an unused credit, it will be refunded to me, less any credit-card processing fees already incurred on the original payment.

V. Consent for Auto-Payment
Unless I make prior arrangements for cash or check, my stored card will be automatically charged according to the schedule in Section III. I understand that I cannot complete the booking process for an intake or one-time appointment unless my card is successfully charged at the time of booking, and that a card on file is required to maintain any appointment on the schedule.

I may revoke this authorization at any time by notifying the practice in writing. Because a card on file is required to hold an appointment on the schedule, revoking it means we would need to make other payment arrangements or stop scheduling sessions.

This is a private-pay practice and I do not bill insurance directly. If you have out-of-network benefits, I can provide a monthly “superbill” — an itemized receipt you submit to your insurer for possible reimbursement. This is optional and you can change it anytime.