Below is a close approximation of the office policies (Treatment
Consent Form) which I use in my practice. Review the various points to get
a sense of how a psychological practice is conducted, and what a new client
can expect of me.
Be advised, though,
that not every practice employs exactly the same policies, and that my policies
conform to California law.
If any mental
health provider does not give you a written office policy statement, you
have a right to ask that all policies be made clear to you before starting
of Confidentiality: All information that
you disclose to me within our sessions is
and will not be revealed to anyone without your written permission (or
your parents permission if you are under 18 years old). Disclosure,
however, may be
or required by law
where there is
a reasonable suspicion of
abuse or elder adult physical abuse;
where there is
a reasonable suspicion that you may present a danger of violence to
where there is
a reasonable suspicion that you are likely to harm yourself unless protective
measures are taken.
may also be required pursuant to a legal
file will consist of (a) legal forms such as this document, (b) a record
of visits and payments, and (c) clinical progress
Training and Experience: I have a
Ph.D. in Clinical Psychology and have a valid license
to practice as a Psychologist in the state of
California (License # PSY 13274). Previous to my
doctorate, I earned an M.A. in Religious Studies and an M.S.E. in Education
in the field of counseling. During the course of
my education I received training in Lacanian
psychotherapy, and hypnosis. After receiving
my Ph.D., I completed a Post-doctoral Fellowship in
Health Psychology. My experience encompasses crisis
intervention, treatment for past child abuse,
trauma & PTSD evaluation and treatment, and treatment
of psychotic, mood, and
and Success of Services: The success of
psychological treatment depends on the motivation and aptitude of the person
being treated, and so I can make no guarantees about treatment success. I allow
you to decide when to terminate the
of Services: You should be aware that, although
I anticipate otherwise, despite treatment you may not improve at all, you
may not improve as quickly as you might like, or you may start to improve
only after treatment has ended. You should also be aware that treatment is
intended to induce change in your life, and that when this change occurs
it may disrupt your accustomed manner of living and your relationships with
others. Treatment can also provoke feelings of affection for me or anger at
me, and these experiences should be considered normal aspects of the treatment
to be discussed openly with me.
Rights: You may request to review information
that I have about you. You have the right to terminate
treatment at any time.
In all cases,
professional treatment never includes sexual contact with the treatment
for Service: You will be expected to pay for
services at the time they are rendered, unless other arrangements have been
made. Payment can be in cash (which ensures confidentiality), by check, or with
a credit card.
If you pay by
a check that is ever returned for insufficient funds, I will expect you to
make good on the check and to pay me for any service charges levied by my
In general, large
balances should not accrue, and we will work to prevent this from happening.
As a last resort, I reserve the right to use a collection agency if you
do not pay a large balance.
Care: I do not accept
Reimbursement: If you carry insurance, please
understand that my professional services are rendered and charged to
you, not to the insurance company. If you request, I will provide
you with a monthly statement which you can submit to your insurance company
for reimbursement. This statement will include your diagnosis, the procedure
code, the number of sessions, and the amount you have paid me, but for my protection
from identity theft I will not reveal my Social Security number to any insurance
company. It will be your responsibility to contact your insurance company to determine
if it will reimburse you under these terms, and, if so, what percentage of the
fee it will cover.
Be advised, however,
that your use of insurance will breach the
of your treatment.
The scheduling of an appointment involves
the reservation of time specifically for you, and I will wait the entire
session time for you to arrive. If you are late, we will meet for whatever
amount of your time remains. You will be required to pay for
the full session. A minimum of 24 hours notice is required for rescheduling
or cancellation of an appointment. If you make two minimum-notice
cancellations back to back, I may give your weekly reserved time to someone
else and place you on an as-available schedule. A feeequal to your
regular session feewill be charged for missed sessions and late
companies cannot be billed for missed sessions, please understand that if
you are using insurance coverage you will always be personally responsible
for paying the charges for late cancellations and missed
calls: While I am waiting for you to arrive
for a session, I will have my phone switched on so that you may call to
report any delays. I switch off my phone during sessions.
welcome to leave messages on my 24-hour voice-mail at any time. If, in an
extraordinary circumstance, you leave a message requesting that I call you
back, it might take several hours before I can return your call. If you call
in the evening, on a weekend, or over a holiday, I may be unable to
call you back until the next business day. In case of an emergency, leave
a message for me and then immediately contact your local crisis
that, in general, telephone calls are not meant to be a form of free counseling.
If you make repeated requests for telephone support, or if you require extended
time on the phone, I will bill you for my time at the same hourly rate as
your office visits.
Because of the danger of privacy breaches, I discourage
the use of text messages unless they are short, information specific, and do not
refer to any psychological details.
If you choose to contact me through e-mail, keep in mind
that Internet e-mail is not secure and that someone, somewhere, could be reading
anything you write by e-mail. Realize also that if you are using a computer at
your work site your network administrator has the capability to read every piece
of e-mail you send and receive through your company e-mail address.