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 dotogether. There are many different forms of psychotherapy. I have an “eclectic” approach, meaning I draw from avariety of theories and methods that have been effective in helping people deal with their internal and externallives. 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 guaranteea particular outcome. The psychotherapeutic process can sometimes involve upsetting feelings, and, on occasion, aperson may feel worse before feeling better. We will work together to establish goals for therapy. Over time, yourgoals 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 andprofessional ethics also require Psychologists to maintain confidentiality and not to release information about youwithout your written consent. However, I would like to tell you about a few possible exceptions to thisconfidentiality agreement, even if all of them may not apply directly to you:
In all of the circumstances described above, I will try to discuss the situation with you before any confidentialinformation 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, asagreed between us. Fees differ with each modality of treatment.
CANCELLATION POLICY. I charge for missed sessions no matter how much advanced notice time yougive. We will make every effort to reschedule a missed session within two weeks. If I am able to schedule anotherperson during your session time, I would not charge you.
PHONE/ TEXT/ EMAIL POLICY. I do not charge for short conversations (5-10 minutes) over thesedifferent devices. However, I bill on a pro-rated basis any longer contact with you or others about your treatmentthat 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” inany litigation. Should I be subpoenaed or be required by a court to participate in a deposition, give testimony orother 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 yourtreatment at any time. If you decide to leave the treatment, you agree to an appropriate termination, which meansattending 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 terminationby you.
By signing below you indicate that you have read and understood this agreement and give consent to treatment.
New York City Office
92 Remsen St. Suite 1A
Brooklyn Heights NY 11201
Zoom and in-person sessions available
Please note: No insurance accepted only Out-of-Network (OON) benefits
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