This document contains important information related to my professional services and business policies. Please read it carefully. Questions related to this agreement can be discussed at any time. When you sign this document, it will represent an agreement between us. The information provided herein regarding my policies for protecting the privacy of confidential medical information is provided as required by law.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you bring forward. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to consider the things we talk about both during and between our sessions.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation period, I will be able to offer you some initial impressions of how our work together would be helpful and some of the difficulties that we would address if you were to decide to continue with therapy. You should evaluate this information along with your own impressions of whether you feel comfortable working with me. Therapy involves a significant investment of time, money, and energy, so you should think carefully about making this commitment. If you have questions or concerns about our work together, we can discuss them whenever they arise. In general, it would be important for us to discuss your concerns and attempt to address them directly. If you decide at any time that our work together is not satisfactory, I would be happy to help you determine the best course of action to take, e.g., stopping treatment altogether or beginning treatment with another mental health professional.

SESSIONS
I normally conduct an initial evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services that you need. If we decide to work together in psychotherapy, I will typically schedule at least one 50-minute session per week at a time we agree upon. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. Because missed appointments cannot typically be billed to insurance carriers, you will be solely responsible for paying for those appointments.

PROFESSIONAL FEES
My fee is $250 per 50-minute session. In addition to regular appointments, I charge $250/hour for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services may include report writing, extended telephone conversations, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my time.

BILLING AND PAYMENT FOR SERVICES
Unless otherwise agreed upon, payment is expected at the time of service. Based upon your needs, and if mutually agreed upon, I may be willing to negotiate a reduced fee or billing agreement. Payment schedules for other professional services will be determined at the time they are requested.

INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary, I will be willing to call the company on your behalf. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end therapy. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide your insurance company with only the information required in order to meet their administrative needs.

PROFESSIONAL RECORDS AND CONFIDENTIALITY

How The Information In Your Record Is Utilized
My policies regarding your privacy are followed by all persons associated with my practice. The laws of California and the standards of my profession require that I keep treatment records. The information in your medical record is utilized in a number of ways. I use it to plan your treatment and keep a record of the significant issues that we address in treatment. I also use the information to coordinate your treatment with other professionals or to provide information to significant others or family members; information is only provided to those that you have given me permission in writing to communicate with regarding your treatment.

Information in your medical record may also be required by your insurance company or health plan so that the treatment you receive from me can be paid for by the insurance company or health plan. For example, I may need to provide information about a service you received, or I may be required to provide information prior to treatment so that your plan will cover the treatment. In these cases, only information required for payment is provided to the insurance company or health plan. By signing this Consent, you authorize me to provide information to your insurance company as needed for payment for services.

For clients under 18 years of age, please be aware that the law provides parents the right to examine treatment records. It is my policy to request an agreement from parents that they agree to give up access to minor client's records. If they agree, I will provide them only with general information about the treatment, unless I feel there is a high risk that the minor client is facing serious jeopardy or harm. In that case, I will notify parents of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving parents any information, I will discuss the matter with the minor client, if possible, and do my best to handle any objections the minor client may have with what I am prepared to discuss.

In general, the privacy of all communications between a client and a psychologist is protected by law and I can only release information about our work to others with your written permission.

Exceptions To Your Confidentiality
There are some exceptions to your protections, and in general, I will provide information from your record when required to do so by local, state or federal law. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he or she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child, a person over age 65, or a disabled person is being abused or mistreated, I may be required to file a report with the appropriate state agency.

If I believe that a client poses a serious risk to someone, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm him or herself, I may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential.

If a situation occurs that requires that I share information without your written permission, I will make every effort to fully discuss it with you before taking any action. In order to release any information to another party, I will ask that you sign an Authorization to Release Information. You may revoke your Authorization at any time.

YOUR RIGHTS REGARDING INFORMATION IN YOUR MEDICAL RECORD

Right to Inspect and Copy
You are entitled to receive a copy of your medical record unless I believe that receiving that information would be emotionally damaging. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records or receive a copy of your records, I require written notice to that effect and I would expect to discuss your request with you in person. If I deny you access to your records, you can request to speak with an independent colleague of mine. Your request for independent review should also be made in writing. If you are provided with a copy of your medical record information, I may charge a fee for any costs associated with that request.

Right to Amend
If you believe that the information I have about you is incorrect or incomplete, you may ask me to amend that information. It is my practice to accept this sort of request in writing and any information you may wish to add to your record should also be provided to me in written form.

Right to an Accounting of Disclosures
You have the right to request an "Accounting Of Disclosures." This is a list of the disclosures I have made of medical record information. That information is listed on the Authorization To Release Information and will be provided to you at your written request.

Right to Request Restrictions
You have the right to privacy and to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. As noted above, I will not release your confidential information without your written permission. Any restrictions to your Authorization To Release Information should be specified on the Authorization.

Right to Request Confidential Communications
You have the right to request that I communicate with you only in certain ways. For example, you can ask that I not leave a telephone message for you or that I only contact you at work or by mail.

COMPLAINTS REGARDING PRIVACY RIGHTS
If you believe your privacy rights have been violated, you may file a written complaint with me, with an independent colleague of mine, or with the U.S. Department of Health and Human Services, 50 United Nations Plaza, Room 322, San Francisco, CA, 94102. You will not be penalized for filing a complaint.

You have the right to a paper copy of this document and you can request one at any time. I reserve the right to change my policies as outlined herein. If they change, you will be informed of that change and will be provided with a copy of the current document if desired.

CONTACTING ME
I am often not immediately available by telephone. In addition to my private practice, I have other clinical responsibilities at other locations. While I am usually working Monday through Friday between 9 a.m. and 6 p.m., I will not answer the phone when I am with a client. When I am unavailable, my telephone will roll over to a voicemail system that I monitor frequently. I will make every effort to return your call as soon as possible, and typically on the same day you make it, with the exception of weekends and after hours. In emergencies, you can attempt to reach me at my office number and leave an appropriate message. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

If you feel that you can't wait for a return call, you can contact the San Diego Access and Crisis Line (1-888-724-7240) or go to the nearest emergency room and ask for the psychologist or therapist on call. If you are in a medical emergency, call 911.


Your signature below indicates that you have reviewed the information contained in the Consent for Treatment and Notice of Business Policies and Privacy Practices document, that you have received a copy of the document, and that you agree to abide by its terms during our professional relationship. With your signature you are providing me with permission to provide you with my professional services as a psychologist.