State of California, Board of Psychology
Guidelines for Informed Consent for Psychotherapy

1. Limits of confidentiality:

Communications will be held in confidence except: 1. to the extent they suggest acts, past or present, which would result in child or elder abuse or physical injury, 2. in case of legal action on your part which would require disclosure, 3 when you have authorized disclosure to a third party such as an insurance company, or 4. when a court has ordered me to release information. In order to resolve therapeutic impasses or to further the therapeutic process, I may consult with my professional colleagues without revealing your identity.

2. Nature and extent of record keeping:

I keep notes of our meetings, and they remain in my custody

3. Title, training, experience, and special expertise:

Licensed psychologist (1974 in Pennsylvania; 1981 in California PSY 7097)
Ph.D. in psychology from Northwestern University (1971)
Internship in clinical psychology at the University of Pennsylvania (1978-80)
Diploma graduate of the C.G. Jung Institut-Zürich (1987)
Professional member of the C.G. Jung Institute of San Francisco (1993)
Board certified in psychoanalysis by the American Board of Professional
Psychology (1996)
Board Certified in psychopharmacology by the Prescribing Psychologists’ Register
(1996)
Board certified in psychopharmacology by the International College of Prescribing
Psychologists (1999)
Fellow of the American College of Advanced Practice Psychologists (1999)
Member of the Amercian Society of Clinical Psychopharmacology (2000)
Fellow of the American Board and Academy of Psychoanalysis (2013)

4. Probable length of services:

This of course varies with individual circumstance and can be discussed during our initial sessions.

5. Risk of services provided:

Psychotherapy and analysis have the potential to cause disruption in a person’s life and career when changes occur. Change can also be emotionally painful at times. There can be no guarantee of improvement.

6. Alternatives to these services:

There may be alternatives to psychotherapy or analysis which can be discussed during the initial sessions.

7. Fee and relevant billing practices:

The fee will be set at the initial session. It is due when services are rendered. Twenty-four hour notification is required to cancel an appointment without being charged the fee. (Reasons: practical and negative transference will be discussed.) The fee may be raised with one month’s notice. For court appearances, depositions, other legal proceedings, travel, or waiting time for legal proceedings, and report writing for legal or other reasons, I charge a fee of $500 per hour.

8. Rights of person receiving services:

You have the right to discuss with me any matter pertaining to our work together, to terminate services, and to ask for a referral to another qualified provider.

9. Emergency access in a psychological crisis:

I can be reached by telephone though you should not expect an immediate response. If your need is too urgent to wait for my response, contact your county’s emergency mental health services. While I am away, my practice will be covered by another professional. Email and texting should be encrypted when possible in order to protect confidentiality

10. Termination of treatment:

I may terminate treatment if payment is not timely, if prescriptions are not filled (such as seeking consultation, refraining from dangerous practices, coming to sessions regularly, etc.) or if some problem emerges that is not within my scope of competence (e.g., eating disorders). The usual minimal termination for an ongoing treatment process is four to ten sessions, but a satisfying termination to long-term work may take a number of months.

11. Follow-up of treatment:

Follow-up is an integral part of the treatment process, because it serves as a treatment booster for you and a way of learning about how you are and the outcome of treatment for me. I will contact you from time to time for a brief follow-up check in. You may feel free to keep me updated about your address changes, life changes and other developments from time to time, too.

I have read the above and know I am free to discuss any questions I may have.

We will never share your information.
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