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CLIENT INFORMATION AND CONSENT
(The following is a copy of the new client information and consent form which you will be given at your first appointment)
A positive relationship between a client and therapist is essential for therapy to work. As in all relationships, clearly defining the terms of the relationship at the outset will lay the foundation for a successful therapeutic experience -- one built upon trust and understanding. Please take a moment to read and sign the following, and return it with your information sheet. The second copy is provided for you to take home for your reference.
About Therapy
Participating in therapy can help you learn new and important things about yourself and others, as well as new and better ways of handling feelings or problems. While there are no guarantees, coming to therapy should help you feel better and produce beneficial results.
Choosing a therapist is a personal process, and finding an effective match between the client and therapist is not always immediately evident. It is suggested that we meet for approximately six sessions and then re-evaluate. If either you or I should decide that this is not a good match we will together make plans to terminate therapy, at which time I will offer an appropriate number of other referrals should you desire them.
You know therapy is working when you feel less worried, afraid or anxious; problems are being resolved; relationships are improving or you come to feel better about yourself. Sometimes you may feel worse before you feel better. This is a part of the therapeutic process and usually means that you are making progress. You have the right to end therapy at any time, and you have the right to seek alternative ways of meeting your goals such as medication should you choose.
Appointments & Fees
The fee for services was discussed on the telephone, and will be finalized in the first session. Payment is due by cash or check at the close of each session. So that we do not use valuable time from your session, please have your check made out in advance. In order to cover accounting and bank fees, there will be a service charge of $15.00 on any returned check. Please note that both group and individual fees are subject to increase, however should that occur you will be given 30 days advance notice of the increase.
Individual appointments consist of a 50-minute hour while group meetings last for 1 hour and 40 minutes. In order to be effective, therapy needs to take place on a regular basis. The best results will occur when appointments are scheduled consistently and attendance is regular.
Group Therapy
The minimum commitment to group therapy is 12 attended sessions. This is because it takes new members a fair amount of time to feel comfortable with the group and begin to relate to the group in a therapeutic way. When you decide to leave the group permanently you agree to notify me and the group at least 4 sessions in advance in order to properly process the termination with the group.
The fee for group is established before joining group, and is a monthly fee regardless of your attendance. This is because you are taking a slot in group which cannot be filled with non-group clients. The fee is based upon an average four week month, however please know that due to holidays, vacations and long months, group may meet anywhere from three to five times per month.
Couples & Family Therapy
If you are coming for couples or family therapy it is important to know that my primary responsibility is to the relationship or family unit, and not to any one individual. While there may likely be times when I may meet one on one with different individuals, I will not “keep secrets” from others in the relationship. I will hold information gained as confidential, but not information which is destructive to the relationship or which makes working on the goal of repairing the relationship futile.
Insurance
Please understand that your insurance policy is a contract between you and the insurance company, and you are responsible to understand the provisions and any exclusions to your coverage. As such, you are solely responsible for all fees for your therapy, whether or not your insurance company provides coverage. You are expected to pay for therapy at the time of service. I will provide you with an appropriate insurance claim form on a monthly basis for you to submit to your insurance company for reimbursement.
You should also be aware that by using any third party payment source for your therapy, your confidential relationship is impacted. I will be required to submit to the insurance company a diagnosis code, and may be required to supply additional treatment information in order to substantiate that you are dealing with a mental health issue or disorder which they provide coverage for. If you want me to submit information to the insurance company to support your claim, you will need to sign a release of confidential information form.
Telephone Calls
When necessary I will be available to consult with you by phone. Should the consultation extend beyond 10 minutes you will be given the option to continue the phone consultation (time permitting) and pay a prorated portion of your usual hourly rate, or you may choose to schedule an additional session. Please note that I do not carry a pager, but check messages frequently and generally return calls within a few hours. Please note that if you feel like a situation is an emergency, or that you or somebody else is unsafe, please do not wait for me to call back. Contact 911 to resolve the immediate situation, and know that I will contact you as soon as possible.
Confidentiality
You are entitled to a confidential relationship with your therapist. As such your therapy sessions are private, and the content of those sessions will be held in the strictest of confidence and will not be shared with anyone without your written consent. Please know, however, that there are a few important exceptions to confidentiality which you must know about. The following are the legal exceptions to confidentiality:
1. Suspected physical or sexual abuse or neglect of a minor under 18 years of age.
2. Suspected physical, sexual, or financial abuse or neglect of an elder or dependent adult.
3. A client who poses a significant threat of harm to self or others.
Referring Others
If you have the occasion to refer another person who may need my services, simply give them my name and number or pass on one of my business cards. Please know that I cannot contact a potential client who you refer without them calling me first. Please have them inform me that they were referred by you, however be assured that under no circumstances would I breach your confidentiality or even confirm that you are my client without your permission.
Termination
There is no set amount of time it takes to complete therapy as everybody moves through their work at their own pace, having differing needs and goals. Typically, as it becomes evident that you have met your goals of therapy and you are satisfied with how far you have gone in therapy, we will begin to discuss termination. At that time we will make a plan together which may include tapering off sessions over a period of time and/or scheduling follow-up "check-in" sessions. Termination is an important part of the process where changes are reviewed and solidified and together we will bring the journey to a comfortable close.
If for some reason you should decide to end therapy without going through a planned termination, I ask that you agree to come into the office for at least one final session so that we can discuss your decision, and reach closure of our relationship.
Thank you for taking the time to review this consent and information form. Should you have any questions or concerns about anything in this agreement you are encouraged to discuss them with me in session. I look forward to developing a trusting, open, and healing therapeutic relationship with you.
Sincerely,
Scott L. Singer, MA, LMFT California License MFC36777
I have read and understand and agree to all of the terms and conditions stated above regarding therapy. I understand that I am responsible for all charges for services, and agree to pay for services under the terms described above. I hereby give my consent for treatment under the above terms.
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