Tao Te Ching

Thank you for considering my office as a source for psychological services. I appreciate your giving me the opportunity to be of help to you.

This brochure answers some questions clients often ask about any therapy practice. It is important to us that you know how we will work together. I believe our work will be most helpful to you when you have a clear idea of what we will be trying to do.

This brochure talks about the following in a general way:

My view of psychotherapy.

The main goal of treatment.

The length of treatment.

Benefits and risks of psychotherapy.

Consultations and second opinions.

What to expect from our relationship.

About confidentiality.

My background.

About our appointments.

How long does therapy take?

How much does therapy cost?

If you need to contact me.

If I need to contact someone about you.

My Emergency Policy.

Statement of Principles and complaint procedure.

Other points.

Our Agreement.

After you read this brochure we can discuss, in person, how these issues apply to your own situation. This brochure is yours to keep or copy and refer to later. Please read all of it and mark any parts that are not clear to you. Write down any questions you think of, and we will discuss them at our next meeting. When you have read and fully understood this brochure, I will ask you to sign an acknowledgement when we are finished. You may have a copy of this form or any form you sign in my office.

Because you will be putting a good deal of time and energy into therapy, you should choose a therapist carefully. I strongly believe you should feel comfortable with the therapist you choose, and hopeful about the therapy. When you feel this way, therapy is more likely to be very helpful to you. Let me describe how I see therapy.

My theoretical approach is primarily based on Dr. William Glasser's Choice Theory and Reality Therapy. I often incorporate elements of mindfulness, which is a form of self-awareness, into my treatment approach. Research on neurological, social and emotional development and the effects of trauma also play a significant role in my therapy. In addition, I have found that the practice of meditation can enhance the effectiveness of treatment, as can a healthy diet, regular exercise and a healthy lifestyle.

The central ideas in my work are:

We often believe that our behaviors and feelings are caused by what happens in the real world. However, this is not quite true. When we have any kind of experience, it does not affect us directly. Rather, we first give it a meaning through our beliefs about it. For example, if I hear a sound in the kitchen and believe it is made by my wife, I am not bothered at all. But if I believe I believe I am alone in the house, the same sound can bother me a great deal since I will probably think it was made by an intruder. Here we see that feelings and behaviors (my actions about the sound) flow from the active process of thinking about or adding meaning to the actual event (the sound).

I think my approach to helping people with their problems is, in great part, an educational one. Anyone can learn to recognize irrational beliefs, dispute them, and replace them with more rational beliefs. We can, with practice, unlearn irrational beliefs and become happier persons who function better in the world. This is what I mean by an educational approach.

I want you to be able to use Choice Theory, Reality Therapy and mindfulness without me. I encourage you to learn more about what methods are used in these approaches; how well they works, and what possible problems or side effects they may have. I can suggest to you books and articles that explain how it works. Many of these should be available in or through the local library, on-line, or in bookstores. I may also give you copies of articles or handouts that are yours to keep.

I usually take notes during our meetings. You may find it useful to take your own notes, and also to take notes outside the office.

During our first session or two we will be getting to know each other. This is the "assessment" phase of treatment. I will be looking to find out how you see your life and how you want it to be different than it is. By the end of our first or second session, I will tell you how I see your case at that point and how I think we should proceed. I view therapy as a partnership between us. You define the areas of your life you want to change; I use my training and experience to help you identify and make the changes you want to make. Psychotherapy is not like visiting a medical doctor in that it requires your very active involvement. It requires your best efforts to change thoughts, feelings, and behaviors. For example, I want you to tell me about important experiences, what they mean to you, and what actions, thoughts, feelings and physiology are involved. This is one of the ways you are an active partner in therapy.

I expect us to plan our work together. In our treatment plan we will list the areas to work on, our goals, the methods we will use and the time and practice commitments we will make, and some other things. I expect us to agree on a plan that we will both work hard to follow. From time to time, we will look together at our progress and goals. If we think we need to, we can then change our treatment plan, its goals, and its methods.

An important part of your therapy will be practicing new skills that you will learn in our sessions. I will ask you to practice outside our meetings, and we will work together to set up homework assignments for you. I might ask you to do practice exercises, to keep records, and perhaps to do other tasks to deepen your learning. You will probably have to work on relationships in your life and make long-term efforts to get the best results. These are important parts of personal change. Change will sometimes be easy and quick, but more often it will be slow and frustrating, and you will need to keep trying. There are no instant, painless cures and no "magic pills." However, you can learn new ways of looking at your problems that will be very helpful for changing your feelings and reactions.  (Back to top)

As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in your community may mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed or even dangerous. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Therapy may disrupt a marital relationship and sometimes may even lead to a divorce. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.

While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. More often than not, people who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives.

I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress.  (Back to top)

If you could benefit from a treatment I cannot provide, I will try to help you to get it. You have a right to ask me about such other treatments, their risks, and their benefits. Based on what I learn about your problems, I may recommend a medical exam, use of medication or other treatments such as EEG Neurofeedback. If I do this, I will fully discuss my reasons with you, so that you can decide what is best. If you are treated by another professional, I will coordinate my services with them and/or with your own medical doctor.

If for some reason treatment is not going well, I might suggest you see another therapist or another professional in addition to me or instead of me. As a responsible person and ethical therapist, I cannot continue to treat you if my treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, I will help you find a qualified person and will provide him or her with the information needed.  (Back to top)

As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the American Psychological Association, or APA. In your best interests, the APA puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you.

First, I am licensed and trained to practice psychology—not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints.

Second, federal and state laws and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the "About Confidentiality" section of this brochure. Here I want to explain that I try not to reveal who my clients are. This is part of my effort to maintain your privacy. If we meet on the street or socially, I may not say hello or talk to you very much. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship. I leave you the choice of acknowledging that we know each other in public.

Third, in your best interest, and following the APA’s standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.

Even though you might invite me, I will not attend your family gatherings, such as parties or weddings.

As your therapist, I will not celebrate holidays or give you gifts; I may not notice or recall your birthday; and may not receive any of your gifts eagerly.  (Back to top)

I will treat with great care all the information you share with me. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a "release-of-records" form before I can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me.

In all but a few rare situations, your confidentiality (that is, your privacy) is protected by state law and by the rules of my profession. Here are the most common cases in which confidentiality is not protected:

Except for the situations I have described above, my office staff and I will always maintain your privacy. I also ask you not to disclose the name or identity of any other client being seen in this office.

My office staff makes every effort to keep the names and records of clients private. My staff and I will try never to use your name on the telephone, if clients in the office can overhear it. All staff members who see your records have been trained in how to keep records confidential and have signed an agreement to do so.

If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you agree to share these records, you will need to sign a release form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. You may read this form at any time. If you have questions, please ask me.

It is my office policy to destroy clients’ records 7 years after the end of our therapy (or 3 years after a minor child client reaches the age of majority). Until then, I will keep your case records in a safe place.

If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access.

If we do family or couple therapy (where there is more than one client), and you want to have my records of this therapy sent to anyone, all of the adults present will have to sign a release.

You can review your own records in my files at any time. You may add to them or correct them, and you can have copies of them. I ask you to understand and agree that you may not examine records created by anyone else and sent to me. You would need to contact that person to see their records about you.

In some very rare situations, I may temporarily remove parts of your records before you see them. This would happen if I believe that the information will be harmful to you, but I will discuss this with you.  (Back to top)

The very first time I meet with you, we will need to give each other much basic information. For this reason, I usually schedule 90 minutes for this first meeting. Following this, we will usually meet for a 50-minute session once or twice a week, then less often. We can schedule meetings for both your and my convenience. I will tell you in advance of my vacations or any other times we cannot meet. Please ask about my schedule in making your own plans.

An appointment is a commitment to our work. We agree to meet here and to be on time. If I am ever unable to start on time, I ask your understanding. I also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that I will have another appointment after yours.

A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give me at least 24 hours notice. Your session time is reserved for you. If you start to miss a lot of sessions, we will need to talk about whether or not therapy is an important need for you at this time.

I will reserve a regular appointment time for you into the foreseeable future if this is what will work best for you. I often do this for my other clients, as well. Therefore, I am rarely able to fill a cancelled session unless I have several weeks’ notice. I ask that you please let me know if a regularly reserved appointment time no longer works for you.

I request that you do not bring children with you if they are young and need babysitting or supervision, which I cannot provide. In some cases, having your child with you in the therapy session might be appropriate. Please discuss this with me in advance.  (Back to top)

In order to keep costs as low as possible, I ask that services be paid for at the time of service. The cost for services is $140.00 for the initial 90-minute intake assessment and $110.00 per 50-minute hour for counseling and therapy. Fees for group therapy is $45.00 per session. Psychological evaluations are charged at $125.00 per client contact hour, with no additional cost for the time spent scoring tests and preparing reports. Court testimony is charged at $150.00 per hour, with a four-hour minimum, payable in advance. The per-hour charge includes travel time to and from the court. The fee for adolescent sexual behavior assessments is $500.00.

Please note: Evaluation and assessment reports are not released until after the fee has been paid.

Options for payment include cash or check. If you will have difficulty in paying for service, please discuss this with me. If you need to pay by credit or debit card, I will need to know in advance so that I can make arrangements.

I am on several insurance provider panels, and insurance providers have different rates for "in-network" and "out-of-network" providers. Please check with your insurance representative to find out what coverage you have and whether or not I am a network provider, and especially whether or not you need pre-authorization in order to be reimbursed for services. I will be happy to submit insurance forms so that you may receive reimbursement for the covered services you obtain. I am willing to work with you and discuss my receiving delayed payment for insurance work if paying the full fee at the time of service would create a financial hardship. Please let me know prior to or during the initial assessment meeting.

Checks that are returned may result in a $25.00 check return fee for the client unless payment is received by the next session. (Note that this fee is separate from any fees your bank may charge you for overdrafts.)  (Back to top)

I cannot promise that I will be available at all times. Although I am in the office frequently during the week, and sometimes on weekends, I may not always be available to see you on very short notice or in an emergency where you need immediate assistance. Also, I usually do not take phone calls when I am with a client. You can always leave a message with my answering machine or voice mail, and I will return your call as soon as I can. Generally, I will return messages daily except on Sundays and holidays.  (Back to top)

If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you—perhaps a parent, relative, spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned about your harming someone else. Please write down the name and information of your chosen contact person in the blanks provided:

Name: ____________________________________________________________

Address: ___________________________________________________________

Phone: ________________________ Relationship to you:____________________  (Back to top)

If you ever become involved in a divorce or custody dispute after you have been in therapy with me, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first.

Doing follow-up and outcome research is always educational. As a professional therapist, I naturally want to know more about how therapy helps people. To understand therapy better, I may sometimes collect information about clients before, during, and after therapy. Therefore, I may ask you to help me by filling out some questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other areas. I ask your permission to take what you wrote on these questionnaires and what I have in my records and use it in research or teaching that I may do in the future. If I ever use the information from your questionnaire, it will always be included with information from many others so that your identity will be completely anonymous. Your name will never be mentioned, and all personal information will be disguised and changed. After the research, teaching, or publishing project is completed all the data used will be destroyed.

If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies.  (Back to top)

It is my intention to fully abide by all the rules of the American Psychological Association (APA) and by those of my state license and applicable federal laws, including HIPAA (The Health Information Portability and Accountability Act).

Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if your concerns with me are not worked out. I will make every effort to hear any complaints you have and to seek solutions to them. If you feel that I, or any other therapist, has treated you unfairly or has even broken a professional rule, please tell me. You can also contact the state or local psychological association and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you how to file a complaint. You may also contact the state board of professional regulation, the organization that licenses those of us in the independent practice of psychology.

In my practice as a therapist, I do not discriminate against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, as well as being required by federal, state, and local laws and regulations. I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately.  (Back to top)

I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them.

I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.

I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.

I have read, or have had read to me, the issues and points in this brochure. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure, including the limits to confidentiality, the fee schedule and the Emergency Policy. I hereby voluntarily agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here.

__________________________________ __________________________________ ___________

Signature of client                                     Printed name                                         Date

I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time, and have informed him or her of the issues and points raised in this brochure. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here.

___________________________________________ ___________

Signature of therapist                                             Date

I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.

___ Copy accepted by client ___Copy kept by therapist  (Back to top)