Adult Informed Consent Form 2017-02-07T21:22:20+00:00

Adult Informed Consent Form

Adult Informed Consent

Welcome to my couseling practice.

This document contains important information about my professional services and business practices. Please read it carefully and jot down any questions you might have so that we can discuss them. Counseling is different from visiting a medical doctor in that it requires a very active effort on your part. In order to be most successful, you will need to work both during your sessions and at home. Counseling has benefits and risks. Risks sometimes include experiencing uncomfortable feelings like sadness, loneliness, or recalling aspects of your personal history that you find unpleasant. Still counseling has been shown to have significant benefits for people who undertake it. Counseling often promotes a significant reduction in feelings of distress while improving relationships and the quality of life by resolving specific problems. Still there are no absolute guarantees with regard to what will happen. By the end of our assessment period, I will be able to share with you what I think our work together will include. If you decide to continue, you should evaluate this along with your assessment of whether I am a person with whom you feel comfortable working. Therapy involves a commitment of time, money and energy, so you should be very careful about the therapist you select. If you have any questions about my effectiveness as your therapist, we should discuss them whenever they arise. If doubt persists, I will be happy to help you secure an appropriate consultation with another behavioral health professional.

SPECIFICS ABOUT MY PRACTICE

I am a private practitioner in this office. I am licensed and registered with the State of California Board of Behavioral Health Examiners to practice independently as a Licensed Professional Counselor with a Masters degree from California State University, Northridge. I specialize in EMDR (Eye Movement Desensitization Reprocessing) and I am an EMDRIA EMDR certified therapist. Please note that current research is limited to the application of EMDR to trauma related disorders. If you should have questions or concerns about the way that your treatment is preceding, please bring your concerns up directly with me. If, after informing me, you are still dissatisfied or have concerns about my practice methods, you may make any complaints or concerns with the State of California Board of Behavioral Health Examiners, 1625 N. Market Blvd., Suite S-22 Sacramento, CA 95834 (916) 574-7830

PROTECTED HEALTH INFORMATION

Privacy is a very important concern for all who come to this office for help. Due to the complicated nature of federal and state laws regarding your protected personal health information, a "Notice of Privacy Practices (NOPP)" has been created. I suggest that you review a copy of my "NOPP" and ask questions about anything contained in this document. You may also request a personal copy of this notice at any time.

EMERGENCIES

To reach me by phone, you can leave a voice mail message on my office line, which I check frequently. If you are having a clinical emergency and are unable to reach me, please call the CIRT (crisis intervention response team) @ (866) 431-2478. CIRT is available 24 hours a day, 7 days a week. Remember you can always contact 911 for assistance. If you are also seeing a Psychiatrist, I advise that you contact her/him in times of emergent need.

PAYMENT AND FEES

Payment is due at the time services are rendered in cash, credit or check. You are financially responsible for your session and payment is expected at the time of your appointment. The normal rate is $190 for the initial assessment and $130 for follow up sessions. Sessions are generally 45-50 minutes.

Please note:

I am private pay i.e. “out of network” for insurance panels, as well as an outside provider with Kaiser-Permenente. In addition, each insurance company's policies are different regarding whether or not they will reimburse you. We will submit any claims to your insurance company.

Non-counseling administrative requests

You will be billed $130 per hour out of pocket for the time it takes to conduct any additional requests i.e. write letters, fill out forms, consultations, depositions, appearances, phone calls over 15 minutes, or other paperwork. You will be billed $5.00 and .50 per page for copying your records. Returned checks incur cash only service fee of $35.00 in addition to the original check amount.

Resceduling Appointments or Cancellations

Scheduling an appointment is a commitment to attend it. A 24-hour business day’s notice is required for changes in appointments. This fee is not reimbursable by any insurance company and is due before rescheduling your next appointment. If you have repeated no shows or late cancellations, I may not be the right therapist for you and can help refer you to another provider.

MEDICAL INSURANCE AUTHORIZATION

If you are seeking to pursue out of network reimbursement through your insurance company, your signature below authorizes me to communicate with the insurance company should they contact me. You are also authorizing the release of information about your care to your insurance company. The information often required by insurance companies may include, but is not limited to, diagnosis, prognosis, and treatment goals. It is important for you to understand that if you choose to pursue reimbursement through your private health insurance they have the right to your records for the purpose of verifying that services were delivered as billed.

CONSENT TO TREATMENT

Your signature below indicates that you have had an opportunity to read and review this information and that pertinent questions have been satisfactorily answered. Furthermore, it indicates your willingness to abide by its terms and agree to participate in treatment.
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