Introduction.This document is intended to provide important information to you regarding your
treatment. Please read the entire document carefully and be sure to ask me any questions that you may have regarding its contents before signing it. You may have questions about me, my qualifications,
therapy, or anything not addressed here. It is your right to have a complete explanation for any questions you may have, now or in the future. Please feel free to ask questions or share any concerns that may arise.
Although I know this may be uncomfortable at times, your openness and honesty will allow me to better
serve you.
Information About Your Therapist. Whenever you wish, I will discuss my professional background with
you and provide you with information regarding my experience, education, special interests, and
professional orientation. You are free to ask questions at any time about the above, and anything else
related to your therapy or other concerns.
Fees. The fee for service is $130.00 per 60-minute therapy session. I reserve the right to periodically
adjust
the fee. You will be notified of any fee adjustment in advance. Fees are payable at the time that services
are rendered. Please ask me if you wish to discuss a written agreement that specifies an alternative
payment procedure.
If there is a need for telephone contact, with you or a third-party, other than for scheduling purposes, you
understand that you are responsible for payment of the agreed-upon fee (on a pro rata basis) for any calls
lasting longer than 10 minutes.
Appointment Scheduling and Cancellation Policies. Sessions are typically scheduled to occur one
time per week at the same time and day if possible. I may suggest a different amount of therapy
depending 3 on the nature and severity of your concerns. Your consistent attendance greatly contributes
to a successful outcome. Scheduled appointment times are reserved especially for you. If an appointment
is missed, or canceled with less than 24 hours’ notice, you (not your insurance company) may be charged
the full fee for that missed session. Exceptions may be made if you are sick or have an unavoidable
emergency.
Insurance. Please inform me if you wish to utilize health insurance to pay for services. I will discuss
the
procedures for billing your insurance. Although I am happy to assist your efforts to seek insurance
reimbursement, I am unable to guarantee whether your insurance will provide payment for the services
provided to you. The amount of reimbursement and the amount of any co-payments or deductible
depends on the requirements of your specific insurance plan.
You should be aware that insurance plans generally limit coverage to certain diagnosable mental
conditions, which then become part of your medical record. You should also be aware that you are
responsible for verifying and understanding the limits of your insurance coverage. You are responsible for
obtaining prior authorization for treatment from your insurance carrier. Please discuss any questions or
concerns that you may have about this with me.
If for some reason you find that you are unable to continue paying for your therapy, please inform me. I
will help you to consider any other options that may be available to you at that time.
Delinquent Accounts. You understand that you are responsible for all charges incurred and that services
must be paid in full at the time of each visit, unless other arrangements have been made in advance.
Should your account become delinquent, you agree to pay interest at 1.5% per month, and if it becomes
necessary for the account to be referred for collection action, you agree to pay the actual balance due plus
any collection expenses of 30-50% of any balances owing, and any attorney’s fees.
Risks and Benefits of Therapy. Psychotherapy is a process in which we will discuss a myriad of issues,
events, experiences and memories for the purpose of creating positive change so that you can experience
your life more fully. It provides an opportunity to better and more deeply understand oneself, as well as
any problems or difficulties you may be experiencing. Psychotherapy is a joint effort between us. Progress
and success may vary depending upon the particular problems or issues being addressed, as well as
many 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
your part, including an active participation in the therapeutic process, honesty, and a willingness to
change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the
benefits listed above.
Participating in therapy may also involve some discomfort, including remembering and discussing
unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger,
fear, anxiety, etc. There may be times in which I will challenge your perceptions and assumptions and
offer different perspectives. The issues presented by you may result in unintended outcomes, including
changes in personal relationships. Sometimes a decision that is positive for one family member is viewed
quite differently by another. You should be aware that any decision on the status of your personal 4
relationships is your sole responsibility. During the therapeutic process, many people find that they feel
worse before they feel better. This is generally a normal course of events. Personal growth and change
may be easy and swift at times but may also be slow and frustrating. You should discuss with me any
concerns you have regarding your progress in therapy. Due to the varying nature and severity of problems
and the individuality of each patient, I am unable to predict the length of your therapy or to guarantee a
specific outcome or result.
Discussion of Treatment Plan. It is my intention to provide services that will assist you in reaching
your
goals. Within a reasonable period of time after the initiation of treatment, I will discuss with you my
working understanding of the problem, treatment plan, therapeutic objectives and my view of the possible
outcomes of treatment. Sometimes more than one approach can be helpful in dealing with a certain
situation. During the course of therapy, I will draw on various treatment approaches according, in part, to
the problem that is being treated and my assessment of what will best benefit you. These approaches may
include but are not limited to behavioral, cognitive, psychodynamic, system/family, developmental, Inner
Child Healing, and/or psycho-educational techniques.
I believe that therapists and patients are partners in the therapeutic process. You have the right to agree or
disagree with my recommendations. If you have any unanswered questions about any of the procedures
used in the course of your therapy, their possible risks, my expertise in employing them, or about the
treatment plan, please ask and you will be answered fully. You also have the right to ask about other
treatments for your condition and their risks and benefits. If you could benefit from any treatment that I
do not provide, I have an ethical obligation to assist you in obtaining those treatments.
Termination of Therapy.The length of your treatment and the timing of the eventual termination of
your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good
idea to plan for your termination, in collaboration with me. I will discuss a plan for termination with you as
you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or I
determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of
your treatment alternatives. Treatment alternatives may include, among other possibilities, referral,
changing your treatment plan, or terminating your therapy. It is best to discuss this in a planned
termination session if at all possible. Professional Consultation. Professional consultation is an important
component of a healthy psychotherapy practice. As such, I regularly participate in clinical, ethical, and
legal consultation with appropriate professionals. During such consultations, I will not reveal any
personally identifying information regarding you or your situation.
Collaboration with Other Professionals. In order to provide quality services, I often need to
collaborate with other professionals, such as your physician, psychiatrist, past therapists, and/or other
mental health professionals. You will be asked to complete a release of information authorizing these
exchanges; in some cases, I may not be able to provide services without this.
Records and Record Keeping. I may take notes during session and will also produce other 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 the therapist. Should you request a copy of
my records, such a request must be made in writing. I reserve the right, under California law, to provide
you with a treatment summary in lieu of actual records. I also reserve the right to refuse to produce a copy
of the record under certain circumstances, but may, as requested, provide a copy of the record to another
treating health care provider. I typically maintain records for ten years following 5 termination of therapy.
After ten years, your records may be destroyed in a manner that preserves your confidentiality.
Confidentiality. 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 are not limited to, situations where you pose a threat of serious harm to
yourself or someone else; cases involving suspected child, elder or dependent adult abuse; cases in which
I am court-ordered to testify or produce records; or as outlined in the “Notice of Privacy Practices” (copies
available on my website and in the waiting room).
If you participate in marital or family therapy, I will not disclose confidential information about your
treatment unless all person(s) who participated in the treatment with you provide their written
authorization to release such information. However, it is important that you know that I utilize a “no
secrets” policy when conducting family or marital/couples therapy. This means that I do not keep secret
information gathered in individual conversations (whether on the phone or in an individual session) if the
information revealed in some way violates the integrity of the couples/family therapy (such as revealing an
affair, substance problem, or intent to leave the relationship). Such information will need to be revealed to
the other partner for therapy to effectively continue. Please feel free to ask me about my “no secrets”
policy and how it may apply to you.
Psychotherapist-Patient Privilege. The information disclosed by you, as well as any records created, is
subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the
special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client
privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapistpatient
privilege. If I receive a subpoena for records, deposition testimony, or testimony in a court of law, I will
assert the psychotherapist-patient privilege on your behalf until instructed, in writing, to do otherwise by
you or your representative. You should be aware that you might be waiving the psychotherapist-patient
privilege regarding your entire treatment if you make your mental or emotional state an issue in a legal
proceeding. You should address any concerns you might have regarding the psychotherapist-patient
privilege with your attorney.
Patient Litigation. I will not voluntarily participate in any litigation or custody dispute in which you
and
another individual, or entity, are parties. I have a policy of not communicating with patients’ attorneys and
will generally not write or sign letters, reports, declarations, or affidavits to be used in any patient’s legal
matter. 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 any time spent for preparation, travel, or other time in which I have made myself
available for such an appearance at my usual and customary hourly rate for such services of $130.00 per
hour.
E-mail and Phone Communication. Some patients prefer to communicate about appointment times or
other administrative issues via e-mail. Although information stored on my computer is encrypted, email
transmitted through regular services is not encrypted. This means that a third party may be able to access
information in an e-mail and read it, since it is transmitted over the Internet. In addition, once the e-mail is
received by you, someone may be able to access your e-mail account and read it. This may include your
employer if you use a work-related e-mail address. E-mail should be considered to be more similar to a
“post-card” than to a sealed letter, and for that reason I discourage sending any clinical or 6 other sensitive
information via e-mail. Please use the telephone for anything urgent or time sensitive, as I cannot
guarantee that I will see an emergency email.
Also, please be aware that phone messages are stored on a password-protected server for up to 30 days,
similar to a cellphone server. Please ask if you have questions about this.
Please initial the options that meet your needs. You can change this at any time by communicating to me
in writing.