Consent Form
Informed Consent Agreement
This document contains important information about my professional services and business policies. Please read it carefully, making note of questions you have so that we may discuss them. When you sign this document, it will represent an agreement between us.
Professional Services
Depth psychotherapy utilizes many different methods to help you deal with the problems you hope to address. What distinguishes Depth psychotherapy from other practices is its attention to the unconscious. It aims to uncover the cause rather than alleviate the symptoms of discomfort. In order for the therapy to be most successful, you will be encouraged to work on things you may have unconsciously buried because of their distressing impact upon you. Therapy aims to provide you with the support you need to effectively address those buried issues that continue to create uncomfortable symptoms in seemingly unrelated areas of your life.
Because psychotherapy can have risks as well as benefits, and because there are no guarantees of what you will experience, you have the right to decide to end treatment at any time during our work together. There is no moral, legal or financial obligation other than to pay for services already rendered.
Professional Standing
My Master's degree (M.A. in Counseling Therapy) was obtained from The Pacifica Graduate Institute, an accredited college for counseling psychology in the Depth tradition. I am an Illinois Licensed Professional Counselor (LPC) and National Certified Counselor (NCC). I am a member of the Illinois Health Care Counseling Association, and of the Illinois Counselors Association, as well as of the International Enneagram Institute. My clinical training was completed at the Good Samaritan Hospital in Downers Grove, IL. I am currently completing a 3 year certification program for proficiency in somatic psychotherapy, (Integrative Body Psychotherapy–IBP.) My professional services do not qualify for insurance reimbursement until I obtain professional state licensure, after the requisite post degree Illinois State licensure requirements have been fulfilled.
Professional Records
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of these records unless I believe that seeing them would be emotionally damaging, in which case I would be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we may discuss their contents. Patients will be charged an appropriate fee for time spent preparing information requests.
Confidentiality
Professional records and information you reveal to me during our professional relationship are considered privileged. I have no right to release them to anyone without your knowledge and written consent. Furthermore, your consent may be revoked at any time. However, under certain specific circumstances as delineated below, my professional obligations may legally require that that I divulge confidential and privileged communication from our work together: (1) if you present a danger to yourself; (2) if you present an imminent danger to another person which can include a communicable disease that can be life-threatening to others; (3) if there is reason to believe that child or elder abuse or neglect is occurring, a report must be filed with a state child protection agency; (4) if a legitimate court order is issued.
Every effort will be made to inform you of such obligations, and to discuss the release of information with you before it is divulged. Once such confidential information is released, I cannot control how it is treated. Therefore I cannot be responsible for any injury or claim for damages arising from the release of records or information as required by law.
Professional Fees
The therapeutic hour normally consists of 50 minutes, charged at the rate of $150 per hour. A session and a half is counted as 80 minutes; a two hour session - 110 minutes. You will be expected to pay for each session at the time it is held, unless otherwise agreed. Telephone calls in excess of ten minutes will be charged in half hour increments. In circumstances of excessive financial burden, I am willing to negotiate a fee adjustment in exchange for a signed release for publication rights related to work our together, with all client's rights to anonymity retained and fully protected.
Unless 24 hours notice is given, you will be expected to pay for the appointment unless we both agree that you were unable to attend due to circumstances beyond your control. Balances may not exceed $400.00 after a 30-day billing cycle, unless arrangements have been made in advance. There is a $25.00 service charge on all returned checks.
If your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment including attorneys, collection agencies, or small claims court.
AGREEMENT
This informed consent agreement can be printed and signed, by using the following link:
Click here to view the printable consent form.
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