Office
Policies
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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.
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,
child
& sexual abuse treatment,
trauma
& PTSD evaluation and treatment, and treatment of psychotic,
mood,
and
anxiety
disorders. I have extensively studied the field of
aviation
psychology and hold an FAA private pilot certificate. I am a current
member of the
Aerospace
Medical Association and the
International
Society for Traumatic Stress Studies.
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.
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In all cases,
professional treatment never includes sexual contact with the treatment
provider. |
|
 Payment
for Service: My fee is $150 per 50-minute
session. 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).
|
Often, someone
will say, “That’s too much. I can’t afford
psychotherapy.”
But what this statement really means is this: I can’t afford
psychotherapy on top of all my other expenses.
And when I look at all those “other expenses,” I often find a massive
amount of frivolity. Cable TV. Movies. Personal cell phones. CDs. DVDs. Ball
games and golf. Extravagant dining. Weekend vacations. Drinking and partying.
Cigarettes. Manicurists, massage therapy and hair coloring—and on and
on. And, apparently, to some people all these things have more importance
than mental health. Come to think of it, maybe that’s why they lack
mental health in the first place. |
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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
50 minutes 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. A fee—equal to your regular session
fee—will be charged for missed sessions without such
notification.
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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. |
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Telephone
calls: You are welcome to leave messages
at any time. If you need to speak with me, I will be happy to call you back
and speak for a few minutes. Remember that, in general, telephone calls are
not meant to take the place of an office visit; if you require extended
time on the phone I may have to start billing you for my time. In special
circumstances, I am agreeable to providing treatment over the phone at the
same hourly rate as we have agreed upon for your office
visits.
If you
do request that I call you back, I will try to respond promptly, sometimes
within a matter of minutes, although it may 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 back until the next business day. In
case of an emergency, leave a message for me and then immediately contact
your local crisis services.
E-mail:
I discourage the use of e-mail with established
clients because of the risk it poses to confidentiality. |
