Office
Policies
 |
Below is a nearly exact copy 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
treatment.
Office Policy
Form
Limits
of Confidentiality: All information that
you disclose to me within our sessions is
confidential
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
authorized
or required by law
• |
where there is
a reasonable suspicion of
child
abuse or elder adult physical abuse; |
• |
where there is
a reasonable suspicion that you may present a danger of violence to
others; |
• |
where there is
a reasonable suspicion that you are likely to harm yourself unless protective
measures are taken. |
|
Disclosure
may also be required pursuant to a legal
proceeding. |
|
Records:
Your
clinical
file will consist of (a) legal forms such as this document, (b) a record
of visits and payments, and (c) clinical progress notes. These progress notes
will contain enough information about your treatment to justify it, should
such justification ever become an
issue.
Education,
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 psychoanalysis,
psychodynamic psychotherapy, and
hypnosis. I completed a Post-doctoral Fellowship
in Health Psychology at the Department of Veterans
Affairs Medical Center, San Francisco. My experience encompasses crisis
intervention, treatment for past child abuse,
trauma & PTSD evaluation and treatment, and treatment
of psychotic, mood, and
anxiety disorders.
Probable
Length of Services: Although many clients
elect to pursue long-term, open-ended treatment, some issues can be resolved
in about 25 to 30 sessions, some highly focused issues such as phobias can
be resolved in about 12 sessions, and some hypnosis work may take only 1
or 2 sessions. The success of psychological treatment, however, depends on
the motivation and aptitude of the person being treated. For this reason,
I can make no guarantees about
treatment
length or success.
Risk
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 or anger for the
psychotherapist that must be discussed in the treatment. In short, treatment
may be emotionally painful at times. Such is the nature of
growth.
Your
Rights: In a private practice such as this,
treatment is entirely voluntary, and you have the right to
terminate
treatment at any time. If for any reason your treatment has been ordered
by a third party, you will be fully informed of this.
|
In all cases,
professional treatment never includes sexual contact with the treatment
provider. |
|
 Payment
for Service: My fee is $150 per 50-minute
session, the current standard rate for psychologists in San Francisco. 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, by check, or with
a credit card (Visa, MasterCard, Discover, or American
Express).
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
bank.
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.
Managed
Care: I do not accept
managed
care.
Insurance
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. It will be
your responsibility to contact your insurance company to determine if they
will reimburse you under these terms, and, if so, what percentage of the
fee they will cover.
|
Be advised, however,
that your use of insurance severely jeopardizes the
confidentiality
of your treatment. |
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Cancellation:
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, of course, 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 fee—equal to your
regular session fee—will be charged for missed sessions and late
cancellations.
|
Because insurance
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
sessions. |
|
Telephone
calls: While I am waiting for you to arrive
for a session, I will have my cell phone turned on so that you may call to
report any delays. I turn my cell phone off during sessions and on days when
I am not in my office.
You are
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
services.
Remember
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.
E-mail:
I discourage the use of e-mail with established
clients because of the risk it poses to confidentiality. |
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