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Agreement for Service/Informed Consent

            I would like you to understand my office policies, approach to treatment and the legal and ethical guidelines that make up the structure of the professional services that I provide.

            A clear understanding and framework provide you with some necessary preliminary information that often make it safer for one to feel comfortable sharing their personal thoughts and feelings.

            Although some of the following may sound “legalistic", it is important that you read through it thoroughly and be sure you understand all that is provided for you.

            If you have any questions, please ask me. When finished, if you have no questions, sign the form which becomes our agreement to begin working together. 


Risks and Benefits

            Psychotherapy is a process in which Therapist and Client often discuss a myriad of issues, events, experiences and memories for the purpose of creating a positive change so one can experience life more fully. It provides an opportunity to better and more deeply understand one self, as well as to discuss any problems or difficulties you may be experiencing.

            Psychotherapy is a joint effort between Client and Therapist (you may also want to read the Treatment Philosophy section). Progress and success may vary depending upon the particular problems or issues being addressed, as well as other factors.

            Participating in therapy may result in a number of benefits to you, including, but not limited to: reduced stress and anxiety; a decrease in negative thoughts and self-sabotaging behaviors; improved interpersonal relationships; increased comfort in social, work and family settings; increased capacity for intimacy and increased self-confidence. Such benefits may also require substantial effort on the part of you, including an active participation in the therapeutic process, honesty and a willingness to change certain feelings, thoughts and behaviors.

            However, there is no guarantee that therapy will yield any or all of these benefits to you.

            Participating in therapy may also involve some discomfort, including: remembering and discussing unpleasant events, feelings and experiences; strong feelings of sadness, anger and fear. These may result in some unintended consequences, such as changes in personal relationships. Client should be aware that any decision on the status of his/her relationship is the responsibility of Client.

            Sometimes because of the process of dealing with a myriad of emotions, Clients may feel worse before they feel better. This is not entirely abnormal. Personal growth may be easy and swift at times, but may also be slow and frustrating. You should address any concerns you have regarding your progress immediately with me.

Professional Consultation

            Professional consultation is an important consideration of a healthy psychotherapy practice. As such, I regularly participate in clinical, ethical and legal consultation with appropriate professionals. During such consultation, I do not reveal any personally identifiable information.

Records and Record Keeping

            Although I rarely take notes during the session, I do produce notes and records regarding your treatment. These notes constitute my clinical and business records, which by law, I am required to maintain. Such records are the sole property of my office practice. I will not alter any records at the request of a Client. Should you request a copy of your records, such a request must be made in writing. As a therapist, I reserve the right, under California law, to provide a summary in lieu of the actual records. I may also reserve the right to refuse to copy the records if I believe they may have a negative impact. In this case, you may have another designated health care provider, under certain circumstances, review your records.

            I will maintain your records for seven years following your termination from therapy. After that, I have the right to destroy your records in a manner that preserves confidentiality. 

Confidentiality

            The information disclosed by you is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality include, but not limited to: reporting child, elder and dependent adult abuse; when a Client makes a serious threat of violence towards a reasonably identifiable victim; or when a Client is a danger to him/herself or the person or property of another. 

 Client Litigation

            I will not voluntarily participate in any litigation, or custody dispute in which you and another individual or entities are parties. I have a policy of not communicating with your attorney and will generally not write letters, reports, declarations or affidavits in your legal matters. I will generally not provide records or testimony unless compelled to do so.

            Should I be subpoenaed, or ordered by a court of law to appear as a witness in an action involving you, you agree to reimburse me for preparation, travel, or other time in which I have made myself available for such an appearance at my usual and customary fee ($125/hour). 

 Psychotherapist-Client Privilege

            All information disclosed by you, as well as any records created, is subject to the psychotherapist-client privilege. This results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege. Typically, the Client is the holder of the privilege. For example, if I were to receive a subpoena for your records, deposition testimony or testimony in a court of law, I would assert this privilege on your behalf until instructed, in writing, to do otherwise by you or your representative. You should be aware by waiving this privilege you are making your mental and/or emotional state an issue in a legal proceeding. You should address any and all concerns you might have regarding the psychotherapist-client privilege with your attorney.

 Fee and Fee Arrangement

            The usual and customary fee for service is $125 per 50-minute session. I reserve the right to periodically adjust this fee. If I do so, you will be notified in advance. In addition, this fee may be adjusted by agreement with me.

            Clients are requested to pay for services at the beginning of each session. Checks and cash accepted. Credit cards (MasterCard, Visa, Discover, etc) are also accepted, but do carry a 5% processing fee..


 Insurance Payments

            I am no longer a Provider for Insurance Companies; meaning that all Clients are required to pay their fee at the time of service. I will provide you with a "Superbill" (receipt) by request at the end of any given month for you to submit to your Insurance Company on your own behalf.

             If you want to know how much you will receive from your Insurance Company, you may want to call them and ask, "What will I be reimbursed when I see an 'out-of-network' provider for out-patient mental health services".

 Cancellation Policy

            You are responsible for payment of the agreed upon fee for any missed session(s). You are also responsible for full payment of session in which you fail to provide 24 hours notice (i.e. if you have a 10am appointment on a Tuesday, you must make contact by 10am on Monday via phone or email). 

 My Availability

            My office is equipped with a confidential voice mail system that allows you to leave a message at any time. I make every effort to return phone calls within 24 hours (or by the next business day), but cannot guarantee that the call will be returned immediately. I am unable to provide 24 hour crisis service. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911 or go to the nearest emergency room.

            Also, although I use email correspondence to schedule appointments, it is not a confidential source of communication and it is suggested that it be used only for that. If you have more detailed information you would like to provide, please call or discuss in session.

 Termination of Therapy

            You have the right to terminate therapy at any time, at your discretion. If you are feeling like you need to or would like to end treatment, please discuss this with me as early as possible. Closure in therapy is important and is usually aided by having several sessions to process the decision.

            I also reserve the right to terminate therapy at my discretion, often because good therapy ends. But there can be other circumstances to which I might propose ending treatment. Reasons for termination may also include, but not limited to: untimely payment of fees; failure to comply with treatment recommendations; conflicts of interest; failure to participate in therapy; or your needs are outside my scope of competence or practice.

            I will attempt to make any transition as smooth as possible, working with you and any subsequent professional.

Acknowledgement

            By signing below, you acknowledge that you have reviewed and fully understand the terms and conditions of this Informed Consent Agreement. You also have addressed any questions you may have about this form.

            Client also agrees to hold Therapist free and harmless from any claims, demands or suits from damages from injury or complications whatsoever, save negligence, that may result from such treatment.

To Create a Version of this Form to Print,  click here Informed Consent1

If you are also using Telemedicine (Skype), be sure to fill this form out as well.

Telemedicine Informed Consent Form.docx