Consent for Treatment

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully, and we can discuss any questions you have at our next meeting. Once you sign this, it will constitute a binding agreement between us.


Psychotherapy is not easily described in general statements. It varies depending on the personality of both the therapist and the client, and the particular problems the client describes.

Psychotherapy requires a client’s honesty, openness, and active effort in order to be successful. Psychotherapy has both benefits and risks. The risks may include experiencing uncomfortable levels of feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and/or helplessness.

Psychotherapy may involve recalling unpleasant aspects of your life history. I may call into question some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged or disappointed.

However, psychotherapy has been shown to have benefits. It can lead to a reduction of feelings of distress, better relationships, and resolution of specific problems.

Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. For example, psychotherapy may result in changing your previous decisions about behavior, employment, substance use, housing, parenting, and partnership.

Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Sometimes change will be easy and swift, but more often it will be slow, and may even be frustrating. There are no guarantees that therapy will yield positive or intended results.


Initial evaluations generally require at least two to four sessions. After evaluation I will be able to offer some possibilities and recommendations concerning our work together. If you decide to continue, we will collaborate on developing a treatment plan.

During this evaluation time, we can both decide whether I am the best person to provide the services that you need in order to accomplish your treatment objectives. The psychotherapeutic approaches I use include analytic, cognitive-behavioral, developmental, Jungian, experiential and psycho-educational.

Please ask me about any approaches or techniques you would like to have information about.

We’ll review your treatment plan periodically, at least annually, to make sure we continue to work towards your goals in therapy. Please be aware you always have the right to refuse any recommended treatment.

If you have any questions about me as your therapist, we should discuss them whenever they arise. If your doubts persist, I will be happy to refer you to another behavioral health professional. Also, it is your right to terminate therapy at any time, although this decision is usually made as part of our therapeutic relationship.


If we initiate psychotherapy, we will schedule a 50-minute session, one appointment hour of 50 minute duration per week at a mutually agreed upon time, although sometimes sessions will be longer or more frequent. If possible, I will try to schedule you at the same time every week.

This way we will be able to notify one another, far in advance, of scheduled conflicts such as vacation,or other appointments.

If you are coming in less frequently that once a week, it may be difficult for me to save a specific time and day. Once your appointment hour is scheduled, you will be expected to pay for it. However, we may both agree that you were unable to attend due to circumstances beyond your control, and I will always try to find another time to reschedule your appointment.


My professional fee is $125 to $150 per hour session. A sliding scale may be available to clients who may require it to make treatment affordable.

In addition to office sessions, it is my practice to charge this amount for telephone therapy sessions. I charge on a prorated basis for other services you may require: report writing, telephone calls which last longer than five minutes, attendance at meetings, consultations with other professionals you have authorized, and any other services which you may request of me.

In unusual circumstances you may become involved in a lawsuit that may require my participation. You will be expected to pay for the professional time required, even if I am compelled to testify for another party. I charge $200 per hour for the preparation of, and attendance at any legal proceeding.


Unless we agree otherwise, you will be expected to pay for each session at the time it begins. Monthly billing is occasionally available upon individual request.

In cases of unusual financial hardship, I may be willing to negotiate a fee adjustment or installment payment plan. There will be a $25 fee for all returned checks. I do not use collection agencies or small claims court.

If you are unable to pay your bill, please talk to me. I will always try to be flexible with unusual circumstances. Payment for other professional services will be negotiated at the time they are requested.


It is your responsibility to evaluate the resources you have available to pay for your treatment. If you have a health-benefits policy that provides coverage for mental health treatment, I will provide you with whatever information will facilitate your receipt of those benefits.

However, you, not your insurance company, are responsible for payment of the agreed fees. You should be aware that most insurance plans require you to authorize me to provide a clinical diagnosis and sometimes, additional clinical information, such as a treatment plan or summary, or in rare cases, a copy of the entire record.

This information about you will become part of the insurance company’s files and in all probability will be computerized. All insurance companies claim to keep such records confidential. However, once it is in their hands, I have no control over it.

I will provide you with a copy of any report that I submit, at your request.


I am often not immediately available by telephone. I am usually in the office from 9am to 6pm on Mondays, Tuesdays, Wednesdays and Thursdays for regularly scheduled appointments.

I do not answer the telephone when I am in session. My office number, 520-749-2075, is a cell phone. I retrieve voice mail messages several times a day during my working weekdays. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays.

Please note that if you call me on a cell phone and since I will return your call on my cell, the privacy of our communication cannot be guaranteed.

If you cannot reach me and you feel you cannot wait for me to return your call, please contact one of the following resources:

1) your primary care physician or other healthcare provider;

2) the emergency room of the nearest hospital (ask for the psychiatrist on call);

3) Help On Call Crisis Line (323-9373); or

4) Call 911 Emergency Line

If I am unavailable for an extended period of time, I will provide you with the name of the mental health professional that is providing clinical coverage for my practice. His/her name and number will always be on my office voice mail message.


Both the law and the standards of the counseling profession require that I keep appropriate treatment records. You may at any time sign a Release of Information to obtain a copy of your treatment record or I can prepare an appropriate summary.

Because these are professional records, they can be misinterpreted and/or be upsetting to a client. I recommend you view the records in my presence so we can discuss the contents. You will be charged for any preparation time that is required to comply with an information request.

I only see clients less than 18 years of age under specific circumstances. If you are under 18 years of age, please be aware that the law does provide your parents with the right to examine your treatment records.

It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about how your treatment is proceeding unless I feel that you are in some danger, in which case I will notify them of my concern.

Before giving your parents any information, I will discuss the matter with you and will do the best I can to resolve any objections you may have about what I am prepared to disclose.


In general, the law protects the confidentiality of communication between a client and professional counselor, and I can only release information about our work to others with your written permission.

For example, if you are in therapy with me, and your partner, child or family member is working with another therapist, I may ask you to sign a dated Release of Information so that I may consult with the other therapist(s).

However, there are a number of exceptions where your written permission is not required:

• A judge may require my testimony if he/she determines that resolution of a court proceeding requires it.

• If I believe a child, an elderly person or a disabled person is being abused, I must file a report with the appropriate state agency.

• If I believe that a client is threatening bodily harm to another, I am required to take protective action which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization for the client.

• If a client threatens to harm him/herself, I may be required to seek hospitalization for the client or contact family members or others who can help keep the client safe.

These situations rarely arise in my practice. If one does, I make every effort to fully discuss the situation with you, the client, before taking any action.

I find it helpful to consult regularly with other mental health professionals about psychotherapy issues in general and various cases specifically. It is possible that some aspect of your therapy could be discussed.

In these consultations, I make every effort to not reveal the identity of a client. Furthermore, the consultant is also legally bound to keep case information confidential. It is important that we discuss any questions or concerns you may have about confidentiality at our next meeting.

The laws governing these issues are complex, and I am not an attorney. If you need specific advice, formal legal consultation may be desirable. I will provide you with relevant portions of applicable state and federal laws governing these issues at your request.

Your signature indicates that you have read the information in this document, received a copy of this document for your own files, and agree to abide by its terms during our professional relationship.