Treatment Forms

The Intake Form below is for clients who are considered “Private Pay.” This simply means that a private pay client will not be using insurance and would rather pay out of pocket for convenience.

If you are a potential client who has insurance you would prefer to use, then you do not need to fill this form out and you can access my Headway portal link to establish yourself as a client.

For Hypnotherapy, you can also access the form below as a new client for hypnotherapy. I don’t accept insurance for hypnotherapy.

Client Intake Psychotherapy/Counseling

If you are a new potential client seeking psychotherapy/counseling sessions, please fill out the following for,m in its entirety.


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Dr. Rodney Luster                    512.423.6684          

New Client Diagnostic Form

For first time clients, this form provides the psychotherapist with your historical system as potentiating facts in your background. Please take your time and fill it out completely

Below are a few common challenges people face. You may not be here or you may have some symptomology. Check any that apply right now for you or add.

Anxiety arising from
Anxiety level from 1-10
Anxiety level1 = low and 10=high
Mood level from1-10
Mood1=low and 10=high
Self/Identity Issues
Cognitive/Thinking Issues
Other challenges


Informed Consent

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and note the questions you have so we can discuss them at our next session. When you sign this document, it will represent an agreement between us and it will become part of your clinical record.


Psychotherapy and counseling practice varies depending on the goals you hope to achieve and the approach of the practitioner. It is therefore important you take care in selecting a therapist that fits your style and goals. Our first few sessions will involve an evaluation of your current concerns, needs, history, and hopes for treatment. By the end of the evaluation, I will be able to offer you my clinical impressions and a recommended approach to treatment. During this time, we can decide if I am the best person to provide the services you need to meet your therapy goals. As therapy involves a commitment of time, money, and energy, it is important you feel comfortable working with me.

If we agree to begin the journey of treatment together, we will cooperatively determine how often we might meet in order for you to achieve your goals. My approach to treatment is eclectic, based on a mosaic of 20 years in academe teaching, professional credentialing, and researching, as well as work in the field, attempting to understand and looking for the proven and evidenced-based potentials alongside experiential approaches to addressing client issues.  As a practitioner applying knowledge and skills that are working towards fostering a better quality of life for the client, there is the imperative need for collaborative engagement between client and counselor, whereby we address potentials together, setting goals, and measuring outcomes. In order for therapy to be most successful, it is recommended you also actively attempt to work on things we discuss both during and external to our sessions. If at any time during your treatment you have questions or concerns about our work together, please bring them to my attention.

Psychotherapy and counseling can have many outstanding benefits and also some inherent risks. Because therapy involves discussing difficult aspects of a person's life, they may experience uncomfortable feelings like sadness, guilt, frustration, anxiety, or anger. These emotional variants can be a form of "constructive discomfort" that has a purposeful outcome. Therapy is not meant to be harmful or hurtful in any way but in order to treat, it is necessary to understand the origins and dimensions of issues to better align therapeutic potentials. Psychotherapy and counseling have been shown to have many excellent benefits. Therapy can lead to improved relationships, solutions to specific problems, and significant reductions in distress. Therapy most importantly can help regulate and treat issues providing comfort to the client and a deeper understanding of who they are. However, the results of therapy can never be guaranteed.

You will be expected to pay for each session at the time it is held. You may pay by cash, or via Paypal. The fee for a 50-minute counseling session is $150.00 unless there is a special being offered for session pricing which does happen at various times or the client has been authorized using a [sliding scale] special fee agreed on by the therapist. Clinical hypnotherapy is $250 for 60 minutes, and a Single session (SSI) is $400.00 for 120 minutes. Bills that are 60 days past due may be placed in collections; I will inform you before I take this measure so that you will have the opportunity to pay promptly. If such legal action is necessary, the costs associated with that action, including attorneys’ fees, will be included in the claim and you agree to pay them. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.

In addition to weekly appointments, I may charge a different rate (prorated according to length) for other professional services you need that may be shorter or longer. Other services may include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, and legal fees (see legal fees for pricing) where preparation of records or treatment summaries must be provided. If you do become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party (please see my forms on legal fees-you should read those carefully before signing this form just so you are aware.


Once an appointment is scheduled you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, regardless of the reason for cancellation. I will make every effort to start our sessions on time. Sessions will end 50 minutes after the scheduled appointment time, even if you are late. If (on rare occasions) I have to begin our session late, I will make up the missed time in some mutually agreeable fashion (e.g., by extending the session, if convenient for you). If it becomes necessary for me to cancel an appointment with you with less than 24 hours notice, you will be charged for the session. Cancellation fees are $75.00 for missed sessions.


You may contact me or reach me via email, my website chat, cellphone, and or my voicemail. However, I am often not immediately available by telephone. Should you need to speak with me directly, I ask that you give me 24-48 hours to respond since I am in session most of the day. If you are in the middle of a life-threatening emergency call 911, contact your psychiatrist or family physician immediately, and/or go to the nearest emergency room.


If I feel a client would be better served with another therapist, or if the relationship is not working conducive to rapport or a very professional relationship itself, I do reserve the right to terminate the relationship with clients. 


I do not engage in relationships via social media networks (Facebook, Twitter, LinkedIn, etc.) with current or former clients. Ethical guidelines, as well as legal statutes of our licensing board, have strict regulations concerning dual relationships, confidentiality, and professional boundaries, which prohibit such contact.


In general, the privacy of all communications between a client and a psychotherapist is protected by law, and I can only release information about our work to others with your written permission. In most situations, I cannot even confirm to a third party that you are being seen in my practice unless you agree to this. However, there are a few exceptions. These situations rarely occur, and if this type of situation occurs, I will make every effort to fully discuss it with you before taking any action.

ONLINE COUNSELING/Counseling/Hypnotherapy

Therapy online, including hypnotherapy, is engaged based on a client's choice of service and agreement to ensure their own privacy wherever they decide to engage in a session whether that be in their own private home space, workspace, car, etc. I include my other services here since a client may decide to include one of the other two services as a potential to complement their treatment. The client is responsible for all issues related to the engagement of online therapy or other services and privacy and any breach of it where a client may be overheard within the proximity of their chosen setting is the client's sole responsibility.

1. I understand that I am about to engage in online sessions with a trained professional.

2. I understand that the online conferencing technology will not be the same as an in-person session I will not be in the same room as the practitioner. I also understand that, in order to have the best results for this session, I should be in a quiet, private place with limited interruptions when I start the session. This also means I am responsible for the privacy of my sessions.

3. I understand the potential risks of such technology, which may include but are not limited to: interruptions, unauthorized access, and technical difficulties. I understand that my practitioner may need to discontinue the session if it is felt that the connections are not adequate for the situation.

4. My practitioner agrees to inform me and obtain my consent if another person is present during the consultation on their side, for any reason. I also agree to inform my therapist if there is another person present during my session and of their right or need to also inquire and stop the session.

5. I understand that there are alternatives to online therapy, coaching, and hypnotherapy that are available, including the option of in-person sessions or potentially finding another provider in my area.

6. I understand that I can direct questions about my session at any time to my practitioner Dr. Rodney Luster.

7. I understand that this consent will last for the duration of the relationship with my practitioner, including any additional sessions I may have. I can withdraw my consent for a session at any time.

8. I understand that the same confidentiality protections, limits to confidentiality, and rules around my records apply to sessions as they would to an in-person session.

9. I agree to work with my practitioner to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions.

10. I understand that my practitioner may decide to terminate services if they deem it inappropriate for me to continue. 

Limits to confidentiality include:

* Reasonable suspicion of child abuse or elder abuse or reasonable suspicion that you present a risk to yourself or others or response to a legal proceeding such as court-ordered therapy or subpoena for records or appearance

As well, because communities may offer up the chance occasion where we may be in the same location, I will always respect your privacy by not greeting you. Please understand, it is not out of rudeness but respect for your confidentiality and the professional relationship we maintain.

HIPPA/Notice of Privacy Practices

Protecting your privacy

Psychotherapists have always managed psychological records with great concern for privacy and confidentiality. I maintain this same level of privacy with life coaching and hypnotherapy. Although the security of records has continuously been addressed by Psychology Codes of Ethics as well as State and Federal laws, the rules have been considerably strengthened by the provisions of the Health Insurance Portability and Accountability Act (HIPAA). The following information provides details about the provisions of the HIPAA and your rights concerning privacy and your psychological (and or coaching and hypnotherapy) records.

Who must observe these rules?

The following individuals are required by HIPAA to comply with the privacy rules:
•. Your treating practitioner. This includes any professional with whom you consult for regular appointments.
•. Any administrative assistant or office staff who may have some access to your identifying information (such as your name, address, telephone number, etc.).
•. Any billing agency or collection agency that handles information about you (name, address, diagnostic codes, treatment codes, consultation dates, but not actual clinical records).

Your rights concerning medical information include:

The right to inspect and obtain a copy of your medical record with limitations (see below): Professional records constitute an important part of the therapy process and help with the continuity of care over time. According to the rules of HIPAA, your consultations are documented in two ways through an overall clinical document and notes:

1) A clinical record may include your reasons for seeking therapy, diagnosis, therapeutic goals, treatment plan, progress, medical and social history, treatment history, and functional status.

You have the right to inspect and obtain a copy of your clinical record. Viewing the record is best done during a professional consultation in order to clarify any questions that you might have at the time. You may be charged a nominal fee for accessing and photocopying the record. 

2) Psychotherapy notes strictly, are not disclosed to third parties, HMOs, insurance companies, billing agencies, the client, or anyone else. They are for the use of a treating therapist and can be misunderstood or even jeopardize the potential of treatment because they are meant to be complex snapshots in time that are understood by the practitioner who used notes technically to observe changes and adjust treatments.

The right to request restrictions on how your information is used.

You have the right to request restrictions on certain uses or disclosures of your information. These requests must be in writing. These requests will most likely be honored, although in some cases they may be denied. Inspirethought LLC does not use or release your protected health information for marketing purposes or any other purpose aside from treatment, payment, healthcare operations, and other exceptions specified in this notice.

The right to request confidential communications

You have the right to request that your practitioner communicate with you about your treatment in a certain way. This may include responses to questions via email, scheduling issues, preference for work versus email communication

How I may use and disclose psychological information concerning you is strictly enforced in the following ways:

For treatment

I will use psychological information about you to assist in the continuity of treatment and services. This information will not be shared with other health care professionals, however, unless you specifically request or agree to it and sign a consent form to that effect.

For payment

I may use and disclose psychological information about you for billing purposes. This is generally restricted to your name and other personal identifiers (address, and other relevant information such as social security number or Medicare number, or other needed information), diagnostic and treatment codes, dates of services, and similar information.

For healthcare operations

I may share basic identifying information with an administrative assistant or other office staff to assist in scheduling or other treatment procedures. This would not normally include the contents of your psychological record.

As required by law

It is possible (but unlikely) that the Department of Health and Human Services may review how I comply with the regulations of HIPAA. In such a case, your personal health information could be revealed as a part of providing evidence of compliance.

Professional associates

I may contract with a billing agency or attorney to attend to business aspects on an as-needed basis. In this case, there will be a written contract in place with the agency requiring that it maintain the security of your information, in compliance with the rules of HIPAA.

Changes to this Notice

Please note that this privacy notice may be revised from time to time. You will be notified of changes in the laws concerning privacy or your rights as I become aware of them. In the meantime, please do not hesitate to raise any questions or concerns about confidentiality with me at any time.

Federal mandate regarding client's rights to receive "good faith" estimates of expected charges under the "No surprises act."

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes

related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

By signing this document, you agree to the following Good Faith estimate for psychotherapeutic services as rendered under the following estimated pricing:

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. This, however, is something that does not occur in my private practice. Clients are billed per session at $200.00 per session.

Make sure you understand the Good Faith Estimate information as iterated herein. For questions or more information about your right to a Good Faith Estimate, visit or speak to your therapist-email

Estimated GFE

Until I do an evaluation and we start therapy, I can’t really predict how long therapy will take, but I typically see patients for 20-30 sessions. However, some/many of my patients have more complex issues that may require as many as 30 sessions during the time frame of this GFE. As well, some patients may feel the need to continue counseling well past this estimated number of sessions. The nature of psychotherapy is as a reoccurring process capturing more complex cognitive details as therapy progresses.

Therapy time span

Typical variable sessions in a year

Rates per session

Typical client lengths beginning psychotherapy and counseling are variable for clients depending on the nature of the issues. Most clients stay with me throughout the year and may do anywhere from 1-4 sessions per month. Some are much shorter.

 15-20 sessions are typical for clients. This does not commit a client to any set number, so clients may benefit from very short-term solutions-based counseling in 1-3 sessions. There is no commitment by clients to any number of sessions.

50 min. session=$150. 

Email/Text Communications

You acknowledge the consent for email communication, text communication (optional). If you wish to contact me for basic communication purposes, sending materials, assignments, or for scheduling appointments. You may email me at You may also receive messages from me via website. The decision of whether to utilize email or any other form of communication with me is solely at your discretion as the client. I do not offer emergency care messages via these channels. You acknowledge that you understand that any communication is not completely secure and that confidentiality in any version of electronic communication does carry inherent risks outside the therapist's scope of influence. You acknowledge that you accept these risks when it comes to various forms of communication that include phone calls, virtual platforms, email, texting, and other forms of electronic communication.

I agree and understand the aforementioned policies and fully consent to treatment. I have provided as well, to the best of my knowledge, accurate and true information in my historical information which will be used in assessing and planning for my treatment.

Acknowledgment and Release of Liability: By signing this form you acknowledge you have read and understand this consent form in its entirety and agree to hold harmless Inspirethought LLC and Dr. Rodney Luster my therapist from all liabilities and claims which may arise as a result of my participation in therapy.*
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Clinical Hypnotherapy Intake Form

The following form is for clients seeking treatment through the use of clinical hypnotherapy. Please read the document in its entirety and fill it out. All sessions are currently conducted online.

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Clinical Hypnotherapy

The following form is a general intake form for those seeking hypnotherapy to help with a variety of issues. This form is also consent for services. Please take your time and fill it out completely.

Medical History
Are any of the following issues prevalent at this time?
Are you pregnant?
What kinds of imaginative imagery that you can picture in your mind would you be comfortable with? ie. someone with a fear of water may not like use of such imagery

Read the following description and indicate the best way you pick up on the following metaphor:

As you look down at your feet, you notice youʼre walking along a dirt trail. You can see little tufts of grass, flowers, and rocks along a winding path through the thick green forest. Now imagine it is a sunny day and you can feel the rays of the sun falling across your face to gently warm it. You can feel the rocks under your shoes, and a cool breeze blowing, lightly caressing your skin, whisping through your hair. Now hear the bluebirds and their noises, a cheerful working melody as they build their nests in the tall rustling trees. A little brook with the sounds of water is flowing in the distance and you know you are nearing a waterfall just around the bend. Now as you turn the corner…”

Help me understand a bit more about your thinking


Terms and Conditions of hypnotherapy

I hereby agree to and provide my full consent to receive hypnotherapy services as a specialized service apart from counseling or as a recommended adjunctive treatment to psychotherapy sessions provided by Dr. Rodney Luster. Dr. Luster has discussed with me how he will engage in hypnosis sessions and all provisioned communication in regard to proper expectations concerning its use. Additionally, such communication provided by Dr. Luster via phone, email, chat, or other communication platforms, has clearly laid out hypnotherapy misconceptions, mythos, and limitations regarding its use.

I also understand that results may vary to different degrees and that results are not 100% guaranteed as every person is unique in their own potentials to engage in hypnosis treatments. Please understand that hypnosis/hypnotherapy is not a substitute for medical treatment and should only be considered a compliment to a balanced approach to a healthy lifestyle. I understand that Dr. Luster is a licensed therapist whose clinical activities are governed by the state and board. He has also been trained as a practitioner of heart-centered hypnotherapy. I am aware and understand that in some cases, where hypnotherapy is used in person and not online, that it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, or wrist in order to assist me in attaining or returning from a hypnotic state. I grant Dr. Luster, as a trusted professional, permission and consent to do so in order to help me establish a beneficial state of hypnosis. I also am aware and completely understand that in hypnotherapy, much as in psychotherapy, it is conceivable that I might experience painful feelings, thoughts, images, or memories that may have been dormant or unprocessed from an earlier time. I have been advised that I am always free and at will to terminate any or all sessions at any time. I have accurately provided background information as requested. I understand that confidentiality will be honored regarding my sessions.

By signing this form, I certify:

● That I have read or had this form read and/or had this form explained to me.
● That I fully understand its contents including the risks and benefits of the procedure(s).
● That I have been given the opportunity to ask questions and that any questions have been answered to my satisfaction.
● That I agree to participate in a video therapy session(s) with your therapist

Acknowledgment and Release of Liability: By signing this form you acknowledge you have read and understand this consent form in its entirety and agree to hold harmless Inspirethought LLC and Dr. Rodney Luster my hypnotherapist from all liabilities and claims which may arise as a result of my participation in hypnotherapy*

By signing I acknowledge the aforementioned material and consent to treatment
SignatureI agree to the terms and conditions
(Sign Here)
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