All applicable state and federal laws are followed with regard to the protection and release of confidential data.  Any
information revealed by you during therapy will be kept strictly confidential and will not be revealed to any other person or
agency without your written permission, with certain limitations.  Additionally, when more than one family member is being
seen in therapy, I may view the couple or family as a whole to be the client.  Therefore, releases of information for couple
or family sessions require the written approval of every consenting member who was present at any time during the
treatment.
You should know that there are certain situations in which Susan K. H. Salzl, MA, LAMFT is required by law or other
exceptions to reveal confidential information obtained from you during therapy to other persons or agencies without your
permission.    Emergency contact names, persons being threatened, law enforcement, designated government agencies,
professional associations and/or other health care professionals may be contacted to ensure appropriate steps have
been taken in accordance with reporting responsibilities and clinical judgment.  The therapist is not required to inform you
of any actions in this regard.  

These situations include:  
1.  An immediate threat of harm to yourself, the threat of you harming others or if you require appropriate emergency
psychiatric care.
2.  Any physical abuse, neglect, or sexual abuse of children or vulnerable adults in the past three years.
3.  Use of an illegal drug for a non-medical purpose during a pregnancy.
4.  Any sexual exploitation by health care professionals.
5.  A court order for specific information, signed by a judge in a pending legal action.
6.  Treatment results of court-ordered therapy
7.  If State or Federal law authorizes the release of your records (e.g. SSI, Work Comp)
8.  An investigation or disciplinary proceeding with a professional association, licensing board or law enforcement agency.
You may be able to use your out-of-network benefits or health-saving accounts for therapeutic services.   It is the
individual's responsibility to check with their insurance provider to verify potential coverage prior to the start of therapy.  
You will be provided with a receipt that can be submitted for reimbursement from your provider.   Your insurance may or
may not cover the services of a Licensed Associate Marriage & Family Therapist (LAMFT).  Generally, I do not code for
medical model diagnosis but you can be provided with appropriate DSM diagnosis codes, if requested.  All charges
incurred are the responsibility of the client.  Insurance companies may require a primary mental health diagnosis for
counseling regarding substance use.

Insurance companies may limit the number of session to be authorized and may require treatment plans and records of
therapy sessions be submitted, which will require the client’s written consent for release.  If the provided receipt is not
adequate for reimbursement, additional fees for insurance report preparation may be required from the client.
The following statements are a limited sampling of general policies and are in no way comprehensive practice policies.  The
policies listed below are examples only and subject to change without notice.  A complete list of current policies is contained
in the Informed Consent Packet sent to each potential new client for their review and discussion.     
Confidentiality
Limitations to Rights
Waivers
Fee-for-Service Advantages
There are advantages to using self-pay for therapy services without out-of-network insurance.

  • There are certain types of therapy that may not be covered by your insurance, such as relationship or couples
    therapy.

  • Your therapy consultation remains completely private, with the limitations to rights of confidentiality listed below.  No
    reports of your treatment are required for insurance and records remain only with the therapist.

  • Medical model diagnosis codes are generally not utilized, unless a client requests them for insurance.  Once
    diagnosis codes are recorded for insurance, they become part of your permanent health care record.

  • Self-pay allows you to make choices about a therapist, type and length of the therapy being considered and what
    treatment options may be available.    
Disclaimer
All information contained on the www.momentuminnovations.com website is ONLY for informational purposes and
subject to change at any time without notice.  Momentum Innovations, LLC and Susan K.H. Salzl, MA, LAMFT assumes
no liability for the contents or damages of any kind for any decision or action by anyone in regards to this website.  
This information is NOT therapeutic or legal advice and any communication does NOT establish a therapist-client
relationship unless an informed consent agreement has been signed by all parties.
If this is an emergency, DIAL 911.
The use of this website establishes your consent to the provisions of this disclaimer.      
Momentum Innovations, LLC

Susan K. H. Salzl, MA, LAMFT
7012 East Fish Lake Rd, Suite 1
Maple Grove, MN   55311
Phone:  763 - 315 - 4598
Insurance
Session Fees
Session Fees

30 minute session -- $60.00
50 minute session -- $110.00
80 minute session -- $170.00
Phone Consultation -- $22.00 per 10 minutes (Therapeutic only)

Susan K. H. Salzl, MA, LAMFT offers a 30 minute new client credit for your first 80 minute intake session.
Call Susan at 763-315-4598 for more details.   

All session fees are due at the time of service.  Cash, checks, Visa, Mastercard, Discover credit cards are accepted.  

Please note:  I will offer you my best in accordance with my training.  However, results are not guaranteed.  Refunds will not be issued.

Canceled, Missed or Late Appointments

I require a 24 hour cancellation notice for any scheduled appointment, except in the case of a verifiable emergency.  
Appointments cancelled less than 24 hours prior to the appointment will be assessed a $60.00 cancellation fee, due
before the next appointment.  

Missed appointments, or “no shows” for a scheduled appointment, will result in full-session session charge, due before the
next appointment.

Clients who are late to scheduled appointments will be charged the full-session fee.
Notice
All information contained on the www.momentuminnovations.com website is the sole intellectual property of
Susan K. H. Salzl, MA, LAMFT and Momentum Innovations, LLC,  who retains and reserves all rights.  Any and all
informational material contained on this website may NOT be copied, reproduced, replicated, altered or borrowed in
any way without the express written permission of Susan K. H. Salzl, MA, LAMFT, Momentum Innovations, LLC.
Copyright 2007.