GWYNNE GILSON, M.S., MFT
LICENSED MARRIAGE AND FAMILY THERAPIST
MFT #47835
OFFICE POLICIES AND CONSENT FOR TREATMENT
Welcome to my practice. I am pleased that you have chosen to begin therapy with me and I look forward to our work together. This document contains important information about my professional services and office policies. It is very important that you understand the information provided here. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign it or at any time in the future.
PSYCHOTHERAPY SERVICES
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights. I, as your therapist, also have responsibilities to you. These rights and responsibilities are described in the following sections.
Psychotherapy has both benefits and risks. Risks may include, for instance, an increase in uncomfortable feelings, especially at first. Working on issues that brought you to therapy in the first place, such as personal orinterpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Consistent attendance at sessions is recommended in order to utilize discomfort or unexpected changes in a transformative way. Psychotherapy has been shown to have benefits for many people. Therapy often leads to the easing of feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, and increased skills for managing stress and solutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires an active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
For those clients who are seeking longer-term therapy, the first 2-4 sessions will involve a comprehensive evaluation of your history and goals. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial plan. You have the right to agree or disagree with my recommendations. If you have questions about the process, we should discuss them whenever they arise.
For those clients who are interested in attending occasionally, or for a brief period, our sessions will more closely resemble consultation than therapy. I will gather as much history as is reasonable in order to appropriately and professionally respond to your needs. The same is true for client primarily interested in doing hypnotherapy with me.
APPOINTMENTS
Sessions are 50 minutes long, usually once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. You are responsible for coming on time; if you are late, your appointment must still end on time.
PROFESSIONAL FEES
The fee we have agreed on is $______per 50-minute session.Please see the separate form “Personal Financial Responsibility Statement for specific information regarding fees, payments, and cancellations.
INSURANCE
I do not accept any kind of insurance. If your insurance company reimburses for out-of-network providers, I will supply you with a bill indicating session dates and fees paid. You are still responsible for paying our agreed-upon fee by the beginning of each session
PROFESSIONAL RECORDS
I am required to keep appropriate records of the services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis (if applicable), topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your payment records. Please ask me if you have questions regarding your records and your rights concerning them.
CONFIDENTIALITY
All communications between you and me will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in couples, conjoint, or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that I utilize a “no-secrets” policy when conducting family or marital/couples therapy. This means that if you participate in family, and/or marital/couples therapy, I am permitted to use information obtained in an individual session that you may have had with me, when working with other members of your family. Please ask me any questions about how this policy may apply to you.
There are exceptions to confidentiality. For example, I am required to report instances of suspected child, dependent adult, or elder abuse. I may be required or permitted to break confidentiality if I think you present a serious danger of physical violence to another person or when you areat risk of self-harm. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the patient that the FBI sought or obtained the items under the Act.
It is very important to be aware that computers and e-mail and cell phone communication, including texting, can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Additionally, my e-mails are not encrypted. Faxes can easily be sent erroneously to the wrong address. My computer is equipped with a firewall, a virus protection and a password. Please notify me if you decide to avoid or limit in any way the use of any or all communication devices, such as e-mail, cell-phone, or texting. If you communicate via e-mail or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via e-mail, cell phone, or texting. Do not use e-mail, texting, or voice mail,for emergencies.
If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality.
CONTACTING ME
I am often not immediately available by telephone. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. I do not return calls on Saturdays or Sundays. In an emergency, to ensure the safety of yourself and/or others, 1) contact your local crisis line (Alameda County: 1-800-309-2131, Contra Costa County: 1-800-833-2900) 2) go to the nearest hospital emergency room, or 3) call 911. Please also attempt to contact me, and leave a message if necessary, to inform me as to what has taken place. I will make every attempt to inform you in advance of planned absences.
OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. I do not have social or sexual relationships with clients or with former clients.
TERMINATION OF THERAPY
The length of your treatment and the timing of the eventual termination of your treatment depend on your own goals and the progress you achieve. It is a good idea to plan for your termination, in collaboration with me. I will discuss a plan for termination with you as you approach the completion of your treatment goals.
You may end therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.
Your signature indicates that you have read this agreement for services carefully and understand its contents. Please ask me to address any questions or concerns that you have about this information before you sign!
Your signature below indicates that you have read this Agreement, understand it, and agree to its terms.
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Signature of Client Signature of Client
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Printed Name of Client Printed Name of Client
______Date Date
FOR MINOR CLIENTS:
I give permission for the above minor (under age 18), to receive psychotherapy services from Gwynne Gilson, MFT. By signing, I certify that I have the legal right to enter the above minor into services.
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Parent or Legal Guardian Date
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Printed Name of Parent or Legal Guardian Relationship to Minor
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