This form tells you about the Federal standard HIPAA rules, and introduces you to how I work and about my policies
I. THE PROCESS
As we begin the psychotherapy process I would like to inform you about the type of work I expect we will do
together. There are many different forms of psychotherapy. I have an “eclectic” approach, meaning I draw from a
variety of theories and methods that have been effective in helping people deal with their internal and external
lives. I tailor my approach to meet your needs.
While benefits can be expected from this treatment, it is important to understand that I can not guarantee
a particular outcome. The psychotherapeutic process can sometimes involve upsetting feelings, and, on occasion, a
person may feel worse before feeling better. We will work together to establish goals for therapy. Over time, your
goals may change and we will work together to review, reassess, and redefine periodically your progress.
As your Psychologist I place a high value on the confidentiality of what you share with me. State law and
professional ethics also require Psychologists to maintain confidentiality and not to release information about you
without your written consent. However, I would like to tell you about a few possible exceptions to this
confidentiality agreement, even if all of them may not apply directly to you:
- As your Psychologist I am required by law to report any suspected child abuse or neglect. This law is designed to protect children from harm.
- In the event that I learn information that could result in danger, injury or harm to you or to your property, or to others or to their property, then I have a duty to notify some other person or official, that in my judgment would reduce that risk of danger.
- If you are currently involved in litigation or become so involved, the court may request a report, an evaluation or your entire mental health record. If you are requested to sign a release for psychotherapy records, you should consult with your attorney.
- If an insurance carrier or a managed care company is paying for a portion of your treatment, you should be aware that your treatment records are available to them upon request: they are likely to put your treatment information into a central computer database that could be accessed by others.
- I may have occasion to consult with professional colleagues about our work together. I will not use your name or other identifying information. If I would like to reveal more general data, I will first seek your expressed consent.
- If I am away or unavailable, and another therapist is covering my practice, it may be necessary for me to share some information about our work together in order for the covering therapist to help you in an emergency situation.
- To PARENTS of TEENAGERS. Other than immediate danger to health and safety of your child, you will not ask for your child’s records without his or her knowledge and written consent.
In all of the circumstances described above, I will try to discuss the situation with you before any confidential
information is disclosed and will reveal only the minimal amount of information necessary.
We will agree on the fee for therapeutic services during the consultation session(s). On January 1st of each year,
I charge a cost-of-living increase (usually 5-10%) : we will discuss this and agree beforehand.
Individual psychotherapy sessions are 45 or 60 minutes in length. Couple, group, and family sessions are longer, as
agreed between us. Fees differ with each modality of treatment.
CANCELLATION POLICY. I charge for missed sessions no matter how much advanced notice time you
give. We will make every effort to reschedule a missed session within two weeks. If I am able to schedule another
person during your session time, I would not charge you.
PHONE/ TEXT/ EMAIL POLICY. I do not charge for short conversations (5-10 minutes) over these
different devices. However, I bill on a pro-rated basis any longer contact with you or others about your treatment
that engages longer time periods.
LITIGATION POLICY. You understand that you are engaging me to provide psychotherapeutic treatment,
not “expert testimony” for a court. As my patient you agree not to require me to provide “expert testimony” in
any litigation. Should I be subpoenaed or be required by a court to participate in a deposition, give testimony or
other services, you agree to pay me for time spent at a rate equal to your current therapy rate.
TERMINATION POLICY. You are making the choice to begin psychotherapy. You have the right to end your
treatment at any time. If you decide to leave the treatment, you agree to an appropriate termination, which means
attending a last session(s) with me. In this way, I can assist you in making plans for future treatment if necessary.
Missing three consecutive scheduled appointments without contact with me will constitute voluntary termination
By signing below you indicate that you have read and understood this agreement and give consent to treatment.