Consent Form

I am providing this information in compliance with the American Psychological Association's Ethics guidelines so that you are fully aware of my office policies and some important ethical issues in the Psychologist/Client relationship.


BEGINNINGS: INFORMED CONSENT TO TREATMENT
During our first session, we will decide whether or not we are a good therapeutic match. For me, this means whether or not I feel that my training and experience are likely to enable me to help you, or whether or not I need to refer you to someone more appropriate for you. Likewise, you will determine whether or not you feel comfortable working with me. In this, and our next few sessions, we will establish your therapeutic goals and I will give you an estimate of how long it typically takes to reach those goals. We will also discuss the nature and likely course of your psychotherapy. A "Doctor-Patient" relationship does not exist until after this initial assessment is completed.
It is also important for you to be aware of the benefits and limitations of psychotherapy. Studies demonstrate that most people benefit from therapy. However, you may experience periods of feeling worse before feeling better, and there is naturally no guarantee of success in therapy. The degree to which you are willing to apply what you learn in sessions to your life is strongly correlated with improvement. Therapy proceeds in stages. As we work together, we will be assessing your progress toward your therapeutic goals. I encourage you to ask any questions you may have about this process at any time during our work together. It will be important for me to hear about any feelings you're having about your therapy.

ENDINGS: ABOUT TERMINATION
The last phase of therapy will begin when we determine that your therapeutic goals have been met. This phase typically lasts several months; its goals include consolidating your treatment gains and making it less likely you will relapse. Abrupt termination can actually be harmful to you, and can undo some of the work you've done here. At the same time, psychotherapy is not meant to go on indefinitely. Ethically, therapy must end when one's goals have been met; one overriding goal is to help you to effectively live your life outside of, and after, therapy ends.


ABOUT CONFIDENTIALITY
State law protects the confidential nature of the Psychologist-Patient relationship. I will not release clinical information about you (including whether or not you are in therapy) to anyone unless given written permission to do so by you (or if one of the conditions applies in the next paragraph). Santa Cruz is a small town; you may encounter me outside of my office. If that happens, I will not acknowledge you in any way unless you acknowledge me first. This protects your privacy.
There are a few situations which allow or require the release of confidential information. 1) The psychologist must act appropriately when there is danger to the patient or to another at the patient's hands. This generally means that the psychologist may involve others when necessary to protect the patient if s/he is suicidal, intends to harm another person, or is unable to provide self-care at a level necessary for basic survival. State law also requires the report of abuse or neglect of a child, elder, or disabled person when there is reasonable belief that it has occurred or is likely to occur in the future. 2) In response to a court order, the psychologist must testify or release records. A psychologist does not release records or testify in response to a subpoena unless the patient or patient's guardian has given written authorization to do so. 3) As professionals, we do consult with one another from time to time to improve our quality of service to you. I also teach psychology courses at U. C. Santa Cruz, and am an author. Case material is sometimes used in training, research, and writing. This is always without identifying information and with great care and respect for your privacy. I rarely use examples from my private practice, but when I do, I disguise any identifying characteristics by changing sex, age, geographical location, and other details about my clients. Any other release of information requires your written authorization.

ABOUT OFFICE & FINANCIAL POLICIES
Emergencies:
I do not provide formal emergency services, yet I wish to be as available as much as is reasonably possible. You may call my voicemail at any time and leave a message. During the day, I often return calls quickly. Nighttime calls will typically be returned the next day. If you find yourself in an urgent situation, make a judgment about the prudence of waiting for my call versus calling 911 or the Santa Cruz County's 24-hour crisis line, 831/458-5300. If I am away, my voicemail message will indicate that and will state when I will return.

Fees & Insurance: I provide a sliding scale in order to help those who cannot otherwise afford psychotherapy. Please advise me if your financial situation changes in either direction. I typically raise my fees every two years from date of initial session in accordance with the average psychologist's fee. I will be glad to help you with your insurance claim by providing a monthly statement, however, it is expected that you will be responsible for the fee at the time of service unless we make other arrangements. As a rule, I choose not to contract with HMOs because of the breach of confidentiality often required by them in order to reimburse you for psychotherapy. Telephone contact under 10 minutes will not be billed. Fifty minute telephone sessions are billed at the same rate as in-person sessions. Court appearances are billed at my per diem rate. Missed appointments or cancellations are billed unless cancelled at least 24 hours in advance of the appointment time. This policy allows use of the time by another client.

Vacations, holidays: My office is closed December 24th-January 2nd, and during major holidays. I typically attend conferences or continuing education classes in March. Additionally, I occasionally deliver papers, speeches, and attend continuing education courses at other times. I take my yearly vacation for 1-2 weeks during late August to mid-September. I will notify you in advance of these specific dates.


Please feel free to ask questions about these policies at any time.


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