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Psychological Services Contract

I appreciate your having decided to pursue psychotherapy with me and want our work together to go well. This document contains important information about my professional services and business policies. Once you sign this, it will constitute a binding agreement.

PSYCHOLOGICAL SERVICES

Psychotherapy takes place between a therapist and client who work together in a way that facilitates the acquisition of insight, understanding, problem-solving, and change. During the first few sessions we will discuss your reasons for coming into therapy and the goals you hope to achieve. I will describe the manner in which I work so that you can decide whether it meets your needs. While I sincerely hope that we will work well together, either of us may decide that the “fit” between personality styles or needs isn’t a good one. In that case, I will be happy to refer you to another therapist whom I believe would be more suitable.

Psychotherapy takes a lot of courage and hard work. You may expect some changes in the way you deal with your day to day living as we proceed. You may notice that you become more introverted and that your life style changes considerably in order to make available the time and energy it requires to work on the issues you have chosen to confront. I will make specific recommendations about skills and tasks I think you should work on between sessions. The duration and pace of our work will depend on your individual ability to deal with the stress and anxiety that emerge as you encounter these issues.

Psychotherapy has benefits and risks. Risks sometimes include the experiencing of very uncomfortable kinds and levels of feeling. Sadness, anxiety, anger and frustration, loneliness, and helplessness are usually felt during the course of treatment. They are common feelings many people experience when they face the intrapsychic and interpersonal problems that brought them to therapy. You may remember difficult and unpleasant aspects of your history. However, psychotherapy has been shown to have benefits for those who undertake it. It often leads to a significant reduction in feelings of distress, better problem solving ability and more satisfying relationships.

By the end of four or five sessions I will be able to offer you some initial impressions of the scope of our work, a diagnostic impression, and a preliminary treatment plan. Since therapy involves a large commitment of time, money, and energy it is important that you are clear about your willingness to allot the resources for it. Any time that you have a question, concern, or are uncomfortable with any aspect of the treatment process I think it is essential that you bring it up. It is important that you continue to feel that you are in the “driver’s seat” i.e. that you are satisfied with the way the treatment is proceeding and want to continue. If you are unhappy with the progress you are making, or the way in which we are working together, and we are unable to resolve the issue, I will be happy to suggest other therapists whom I believe could assist you.

CONTACTING ME

I am often not immediately available by telephone. I have an answering machine that I check often for messages. I do not interrupt sessions to take calls. I will make every effort to return your call on the same day you make it with the exception of weekends and holidays. If you are difficult to reach, please leave some times when you will be available. If you feel that you are facing a psychological crisis, please get in touch with me immediately. In the case of an emergency and you feel that you cannot wait for me to return your call, you should contact your family physician or psychiatrist, go to a hospital emergency room, or call the Mobile Crisis Unit. If I am unavailable for an extended period of time, I will provide you with the name of a trusted colleague whom you can contact if necessary.

LIABILITY DISCLAIMER NOTICE: I am an independent practitioner at 3200 Washington St. I share common areas of office space with the other clinicians in this building. There is no official professional affiliation among any occupant of this building and we assume no legal responsibility for each other’s patients.

PROFESSIONAL FEES

My sessions are 50 minutes in duration and my fee is $250 per session. I will usually schedule one 50 minute session per week at a mutually agreed time, although sometimes sessions will be longer or more frequent. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis for other professional services you may require. For example, report writing, litigation, attendance at meetings or consultations with other professionals which you have authorized, preparation of records or treatment summaries or the time required to perform any other service which you may request of me. You will be expected to pay at the time services are provided. Unless there is an emergency, or you cancel your appointment within 24 hours, you will be expected to pay for scheduled sessions even if you miss them.

Please let me know promptly if your financial situation changes and you cannot pay my regular fee. We will talk about what arrangements can be made. If you do not make arrangements within 60 days I have the option of using collection agencies or small claims court to obtain payment. The cost involved in such action would also be part of the claim. The only information I would make available would be your name, the nature of the services, and the amount due.

INSURANCE REIMBURSEMENT

You will be expected to pay for each session at the time services are provided, unless we agree otherwise. If you have insurance coverage, I am happy to send in claims to your insurance company directly. You will then be reimbursed by your insurance company based on what your plan allows. It is often helpful to call your insurance carrier to find out what benefits are provided for “Out-Of-Network Mental Health” individual sessions prior to beginning treatment.

Many insurance plans are oriented toward short term treatment approaches, i.e. they are designed to resolve specific problems that are interfering with one’s usual level of functioning. I will do what I can to seek approval for the number of sessions I believe our work will entail but I cannot guarantee that I will be successful. Make sure all of your questions are answered before we begin treatment so that we can be clear about what our work may require and what the insurance company will cover. I want to avoid any disruptions surrounding payment and coverage that will interfere with your treatment.

PROFESSIONAL RECORDS

Both the law and the standards of ethical conduct for psychologists require that I keep appropriate records. You are entitled to a copy of them, or a summary. Because these are professional records they can be misinterpreted and/or can be upsetting. So if you wish to see them, I recommend we review them together so that we can discuss whatever they contain in a way that supports your understanding and emotional reactions.

If I am treating two people in the same session I cannot release the records without the approval of both parties. I will do everything in my power to avoid releasing records of couples work for the purpose of divorce litigation. I do not make myself available to testify on behalf of either member of the couple.

CONFIDENTIALTY

In general, the confidentiality of all communications between a client and a therapist are protected by law and I will only release information about you with written permission. However, there are some exceptions you need to bear in mind. If legal issues develop, a court of law has the power to order me to release client records. If I believe that an elderly person, a disabled person, or a child is being abused, I must file a report with the appropriate state agency. If I believe that you are going to cause serious bodily harm to someone else, I am required to take protective action which may involve notifying the potential victim, the police, or seeking to hospitalize you. If you are suicidal, I may seek to hospitalize you until the issues surrounding your suicidality are resolved. I may contact family members to assist with these arrangements.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns you may have at our next meeting. The laws governing these issues are quite complex and I am not an attorney. While I am happy to discuss these issues with you, should you need specific advising, formal legal consultation may be desirable.

MINORS

If you are under seventeen, please be aware that the law may provide your parents with the right to examine your records. It is my policy to respect both the adolescent’s privacy, and the parents’ responsibility to assure that their child receives appropriate professional services. We will carefully discuss any issues before I share my thoughts with your parents, and work to resolve any concerns you may have.

California provides the consumer the opportunity to file inquiries with its Board of Examiners in Psychology. Board offices may be reached at: California Board of Examiners in Psychology, 2005 Evergreen St. Suite 1400 Sacramento, CA 95815-3831

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

Signature

Your name in the field below constitues an electronic signature and indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.




A. Identification




B. Referral

Who gave you my name to call?


Yes No
C. Medical Care

From whom or where do you get your medical care?

Yes No
D. Current Employer
E. Marital/relationship history

First Spouse

Yes No


Second Spouse

Yes No


Third Spouse

Yes No
F. Children

Child 1

Current Previous

Child 2

Current Previous
+ ADD
H. Insurance Information

Authorization to Release Information to My Insurance Company

I hereby authorize Jennifer J. Gans, Psy.D. to release my insurance provider information required in the course of my treatment, as may be necessary.

Name
Date

Assignment of Insurance Benefits

I hereby authorize payment directly to Jennifer J. Gans, Psy.D., of the medical Benefits, if any, including but not limited to Major Medical and/or Supplemental benefits, otherwise payable to me for the services rendered by her.

Name
Date
Authorization