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.
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.
My Master's degree (M.A., Counseling Therapy) was obtained from The Pacifica Graduate Institute, an accredited college for counseling psychology in the Depth tradition (Jungian). I am an Illinois Licensed Clinical Professional Counselor (LCPC), a National Certified Counselor (NCC), a member of the Illinois Health Care Counseling Association (IHCCA) and the Illinois Counselors Association (ICA), as well as a member of the International Enneagram Association (IEA). My clinical training took place at the Good Samaritan Hospital in Downers Grove, IL., and my internship hours were completed at Provena Medical Mercy Hospital's Adult Psychiatric Unit. In addition to my interests in Jungian psychology and the Enneagram, the orientation that grounds my approach remains Somatic Psychotherapy for which I underwent a a 3 year certification program at the Institute of Integrative Body Psychotherapy (IBP) in Sta. Monica, CA. My education also includes 18 months of Clinical Hypnotherapy with Neuro Linguistic Programing using the PAUSE model developed by New Vistas International, in Reno NV; I've also trained and certified at the Institute for Rapid Resolution Therapy, and at the Institute for Survivors of Sexual Violence with Dr. Connely, a nationally known Trauma Resolution expert. My professional services qualify for insurance reimbursement, and I am a preferred provider (PPO) with BCBS of Illinois.
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 by the untrained reader. I stipulate 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.
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.
The therapeutic hour normally consists of 50 minutes, charged at the rate of $160 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.
This informed consent agreement can be printed and signed, by using the following link:
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